Sinclair Community College-UB 1-2023 Application Form 2 Part 1

Student's First Name, Middle Initial, and Last Name*

First NameMiddle InitialLast Name

Student's Date of Birth*

mm-dd-yyyy

Student's Age (at time of completing application)*

Student's Current School*

BelmontMeadowdalePonitz

Student's Current Grade Level*

9th Grade10th Grade11th Grade12th Grade

Student's Gender*

MaleFemaleNon-BinaryOther

Student's Ethnicity (select all that apply)*

Is the student a Sinclair Educational Talent Search participant? (Please note that Sinclair Upward Bound can NOT take in any students who are already a part of Sinclair's Educational Talent Search.)*

YesNoThe student is unsure.

Does the student have a current GPA that is equal to or above a 2.5?*

Yes, the student's current GPA is equal to or above a 2.5No, the student's current GPA is NOT equal to or above a 2.5The student does not know what their current GPA is at the moment.

Has the student filled out a Sinclair Upward Bound application in the past?

YesNoThe student is unsure.

Student's Phone Number*

(999)999-9999

Student's Personal Email Address (Do NOT put your Dayton Public Email Address)*

example@example.com

Parent/Guardian's Phone Number*

(999)999-9999

Parent/Guardian's Email Address*

example@example.com

Does the student give Sinclair Upward Bound permission to text and/or email them?*

YesNo

What language does the student prefer Sinclair Upward Bound communication (texts, emails, etc.) to be sent in?

EnglishSpanishOther

What services/factors/interests make the student want to apply to Sinclair Upward Bound?*

Where did the student hear about Sinclair Upward Bound?

I submit this information to be considered as a participant in the Sinclair Community College TRIO Upward Bound program; I certify that the information is true and correct to the best of my knowledge. I release the following information from public school records to the TRIO Upward Bound program: transcripts, test scores, income, and other information necessary for program application completion, provision of academic support, and verification of student progress. All information provided on this form will be kept confidential and will not be disclosed to a third party by the program without my permission. I understand that my parents/guardians will be required to disclose information, such as household income, necessary to determine my eligibility for program participation.

Student's Signature*

Today's Date*

mm-dd-yyyy

To be considered for the Sinclair Upward Bound Program, students will need to complete Part Two of our application. Please enter your parent/guardian’s information below so that Part Two is able to be sent via email to your parent/guardian’s email. Please be sure to enter all information correctly! For any questions, please email sinclairupwardbound@gmail.com or call 937-512-2331. Thank you!

Parent/Guardian's First and Last Name*

First NameLast Name

Parent/Guardian's Email Address (please make sure that this is accurate!)*

example@example.com

Parent/Guardian's Phone Number*

(999)999-9999

Sinclair Upward Bound Application - Part One - Belmont, Meadowdale, and Ponitz

STUDENT AUTHORIZATION FOR RELEASE OF ACADEMIC RECORDS AND INFORMATION

Sinclair Upward Bound Application - Part Two