UB application

Upward Bound

Carroll Rhodes

Director

Russell Hall 134

570-484-3054

crhodes@lhup.edu

Shawn O'Dell

Secretary

Russell Hall 132

570-484-2409

sodell@lhup.edu

Dear Applicant:

If you are currently in ninth, tenth or eleventh grade and you are interested in attending college, Lock Haven University's Upward Bound Program may be for you. To qualify, eligible students must meet federal low-income guidelines or live with parents/guardians who have not received a four-year college degree.

It is important that you understand that participation in Lock Haven University's Upward Bound requires that (1) attend the five-week summer session (2) participate in all UB activities, assignments, and services provided in your school or community during the following school year. By submitting this application, you are indicating that you are aware of and agree to this commitment if selected.

We are very pleased that you are interested in Upward Bound. Attached are the forms you will need to complete in order to be considered for participation. Please be aware that ALL forms must be COMPLETELY filled out for your application to be considered.

TO BE COMPLETE, YOUR APPLICATION MUST INCLUDE THE FOLLOWING:

MAIL COMPLETED APPLICATIONS TO:

Carroll Rhodes, Director

Upward Bound

Russell Hall 134

Lock Haven University of Pennsylvania

Lock Haven, PA 17745

Phone: 570-484-3054

OFFICE USE:

LI:__________ FG: __________

Begin Date:

End Date:

Date of Graduation:

Missing:

PART 1: STUDENT INFORMATION

Name:_________________________________________________________________

Last First MI

Address: _______________________________________________________________

City: ______________________State: ___________ Zip: __________

Home Telephone No.: ( ) _______________ Soc. Sec. No.: _______-_______-______

E-Mail Address (if you have one): _____________________________________

Date of Birth: ______________________ Sex: _____ Male ______ Female

Citizenship:

I am a U.S. citizen

I am a permanent resident

I am neither. I have applied for citizenship Yes No

*(copy of citizenship application must be included for consideration)

PR No.: _______________________

Ethnic Background:

Black/African American Native Hawaiian/Pacific Islander

Latino/Hispanic American American Indian/Alaskan Native

Asian American White American

Other (Identify: ______________________________________________)

PART 2: SCHOOL/ACADEMIC INFORMATION

Current Grade in School:

9th 10th 11th

Name of High School: _____________________________________________________

High School Address: _____________________________________________________

City: ______________________ State: _____________ Zip: _________________

High School Telephone No.: ( ) ___________________

Name of Your High School Counselor: ________________________________________

Counselor's Phone No.: ( ) ______________________

When is the last day of school this year? _________________________

If you have ever been enrolled in Upward Bound, Talent Search, or any other program that provides specialized educational programs/services, please complete the following:

Name of Program: ________________________________________________________

Director: _________________________________ Phone No.: ( ) ______________

Please Identify your sequence of math and science courses:

Last Taking Next Last Taking Next

Year Now Year Year Now Year

Math Courses Science Courses

Algebra Physical Science

Geometry Environ. Science

Algebra II Biology

Trigonometry Chemistry

Pre-calculus Physics

Courses not listed above: ________________________________________________________

After graduating from high school I plan to:

Attend College Go into the Armed Services Find a job and work

Undecided Other (please describe): _________________________

PART 3: EXTRACURRICULAR ACTIVITIES

List school and community clubs, organizations, and sports that you have been involved in since ninth grade. Identify awards or honors you have received.

______________________________________________________________________________

Identify jobs or volunteer work you have done. You should include any church work, community service, and school or family jobs. Describe what kind of skills you learned.

______________________________________________________________________________

Describe any special interests or hobbies that you have. What do you do after school and on weekends?

______________________________________________________________________________

PART 4: PARENT-GUARDIAN/HOUSEHOLD INFORMATION

FATHER/MALE/LEGAL GUARDIAN:

Name: _______________________________________________________________________

Home address: ________________________________________________________________

Occupation: _______________________ Employer: _________________________________

Home Phone: ( ) __________ Work: ( ) ____________

Check the highest level of education father/male/guardian achieved:

Did not complete high school High School Diploma Trade Certificate

2-year college degree 4-year college degree Masters Degree/Ph.D/Ed.D

MOTHER/FEMALE/LEGAL GUARDIAN:

Name: _______________________________________________________________________

Home address: ________________________________________________________________

Occupation: _______________________ Employer: _________________________________

Home Phone: ( ) __________ Work: ( ) ____________

Check the highest level of education father/male/guardian acheived:

Did not complete high school High School Diploma Trade Certificate

2-year college degree 4-year college degree Masters Degree/Ph.D/Ed.D

I currently live with (check all that apply):

Father Stepfather Male Guardian Other (specify)__________________

Mother Stepmother Female Guardian Other (specify)__________________

Please list all members currently living in your household:

Name Relationship Age

__________________________ _____________________ ___________

Are you a ward of the court? Yes No

PLEASE TAKE TIME TO THINK ABOUT YOUR WRITTEN RESPONSES TO THE QUESTIONS BELOW BEFORE WRITING YOUR ANSWERS. THE BEST ANSWERS WILL BE THOUGHTFUL, STATED IN YOUR OWN WORDS, AND CLEARLY WRITTEN IN INK OR TYPED. IF YOU NEED ADDITIONAL SPACE, ATTACH ANOTHER PIECE OF PAPER.

Identify the academic and/or personal areas in which you believe our program can benefit you. Which UB services do you believe will be most valuable for you?

_____________________________________________________________________________

Identify TWO careers in which you could see yourself employed. Discuss why you are interested in them.

_____________________________________________________________________________

Explain why you believe that you have the potential to successfully complete a degree in college. Share as many specifics about yourself as you can.

_____________________________________________________________________________

Identify a current TOPIC or ISSUE that you would be interested in researching further. Explain why. (NOTE: This is not a question about your career interests.)

_____________________________________________________________________________

PART 6: FINANCIAL INFORMATION

THE UPWARD BOUND PROGRAM IS A FEDERALLY FUNDED PROGRAM.

FOR THE APPLICANT TO QUALIFY, VERIFICATION OF INCOME IS NECESSARY.

IF YOU FILE A TAX RETURN:

What was your family's total annual TAXABLE income for last year? $ _______________

(if you have not completed a tax form for 2001, you may use figures from the form you filed for 2000)

How many family members (adults and children) who live in your household were claimed as

dependents for income tax purposes? _______________________

PLEASE NOTE: A signed copy of the page from your tax form that documents the

taxable income identified above must accompany this application.

IF YOU DO NOT FILE A TAX RETURN:

Identify the source and amount of your nontaxable income.

PLEASE NOTE: Copies to document this income must accompany application.

Monthly Monthly

TANF $ ___________ Disability $ ___________

Unemployment $ ___________ Retirement/Pension $ ___________

Social Security $ ___________ Veterans Benefits $ ___________

Other (specify): _____________________________________

I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

____________________________________________

Parent/Guardian Name (please print)

____________________________________________ _______________________

Parent/Guardian Signature Date