APPLICATION FOR ADMISSION - Savannah State University

[Pages:6]SAVANNAH STATE UNIVERSITY UPWARD BOUND PROGRAM

BOX 20488 3219 COLLEGE STREET SAVANNAH, GEORGIA 31404 (912) 358-3477 FAX (912) 358-3687

Email: upwardbound@savannahstate.edu

APPLICATION FOR ADMISSION (Please Complete All Sections of Application in black or blue ink only)

Name ______________________________________

Last

First

Address

Street

Apt. No.

Telephone1( )

Telephone2( )

Middle

City/State

E-Mail Address

= 7

=

Zip

6

Gender: Female - Male - Date of Birth

Age

6

Please check yes or no:

I am a United States citizen. Yes No

Ethnic Origin (REQUIRED FOR STATISTICAL PURPOSES):

African American American Indian/Alaska Native Asian/Pacific Islander European American (Caucasian) Hispanic More than one ethnic origin (Specify)

Health:

Excellent Good Fair Poor List any physical disabilities/serious health conditions _______________________

Select School:'

___ A.E. Beach ___ S.C. Johnson

___R.W. Groves ___ SOL at Savannah

___H. V. Jenkins

Free

or reduced lunch?

___ 9th Grade___10th Grade

Counselor's Name

Emergency Contact Person

Telephone ( )

Relationship to You

TO BE COMPLETED BY PARENT/GUARDIAN

Parent's/Guardian's Marital Status: Married ___ Divorced ___ Separated ___ Widowed

Single ___

Father's/Guardian's Name

Address

Employer

Occupation

Phone ( )

Did you graduate from high school?

Did you graduate from college?

Name of College?

College was: 4-year

2-year

Annual Gross Income $

Other

Mother's/Guardian's Name

Address

Employer

Occupation

Phone ( )

Did you graduate from high school?

Did you graduate from college?

Name of College?

College was: 4-year

2-year

Annual Gross Income $

Other

List each child living in the household (excluding applicant) below.

NAME

AGE

CHECK IF SUPPORTED

BY PARENT/GUARDIAN

SCHOOL ATTENDING

________

Other Income (Please attach official documentation):

Social Security $ Retirement $

Veterans Benefits $ Unemployment $

- 2 -

TANF/Welfare $ Medicaid Number

I affirm that the information provided is complete and correct. Any deliberate or omission of date supplied may result in denial of placement or dismissal from the Upward Bound Program.

Student's Signature

Parent's/Guardian's Signature

Date

Parental Authorization for Release of Student's Records

Privacy Act In accordance with the Family Educational Rights and Privacy Act, I understand that all information concerning my child and me is confidential and will not be revealed to anyone except Upward Bound Personnel.

I,

, Parent/Legal Guardian of

,

(Please Print)

(Please Print)

authorize the Superintendent of Schools or his/her Designee(s) to release all records listed below to the following Agency

and its Designee(s):

Savannah State University

Upward Bound Program

Box 20488

3219 College Street

Savannah, Georgia 31404

Telephone: (912) 358-3477 Fax: (912) 358-3687

Email: upwardbound@savannahstate.edu

Records:

Grade Transcripts/Progress Reports

Attendance Data

Psychological Education Reports

Testing Data

Special Education Placement Data

Immunization Data

***Student Social Security Number _____________________

I further authorize the release of all information regarding my child's educational, physical and social adjustments in school, as long as he/she participates in the Upward Bound Program.

I also understand that prior to transfer, I may review and have all/any part of these records properly interpreted by making such request of the Principal or appropriate Board of Education Personnel.

Additional Permission Authorization Waiver

I agree to allow all Upward Bound and its constituents to photograph or digitally record my child for use in publications.

I further grant authorization to allow my child to participate in all workshops, seminars, classes, surveys and fieldtrips throughout their participation with the Upward Bound Program at Savannah State University.

Parent(s)/Guardian(s) Signature

Date _____________________

Student's Signature ______________________________________________________ Date _____________________

- 3 Please write a brief autobiographical sketch. Include experiences, interest, activities, and future plans and reasons for desiring to participate in the Upward Bound Program. (In Black or Blue Ink Only)

___________________

NEEDS ASSESSMENT

1. Are you currently participating in any of the following? (check below)

Educational Talent Search

GEAR UP

Other (Please list ____________________________________)

2. How many years of college do you plan to complete after high school graduation? 1-6 months (Certificate Program) 1-2 years (Community/Technical College) 3-5 years (Bachelors Degree) 6 or more (Masters/Doctorate Degree) Not Sure

3. Currently, what career do you wish to pursue?

4. Do you know facts about this career (what to study in college, schools that offer the major, classes needed to take, etc.?

5. To prepare for college, are you knowledgeable of the academic classes that should be studied (college prep curriculum)?

6. Do you need assistance applying for college, financial aid, and scholarships?

7. Do you need assistance in preparing for ACT, SAT, or PSAT Tests?

8. Do you need to develop/improve your study skills?

9. Do you need enrichment/tutoring in any subject? List:

Goal(s) you have set for yourself: Academic:

Program:

Overall:

- 4 -

PLEASE CIRCLE

YES NO YES NO YES NO YES NO YES NO YES NO YES NO

******Student, please turn in to your counselor and have them attach your transcript******

COUNSELOR PLEASE ATTACH STUDENT'S TRANSCRIPT INCLUDING TEST SCORES AND MOST RECENT REPORT CARD. The student will not be considered until a transcript has been received.

- 5 -

SAVANNAH STATE UNIVERSITY

UPWARD BOUND PROGRAM BOX 20488 3219 COLLEGE STREET SAVANNAH, GEORGIA 31404

(912) 358-3477 FAX (912) 358-3687 upwardbound@savannahstate.edu

TEACHER'S RECOMMENDATION

Please give specific reasons for recommending this student to the Upward Bound Program and return to the above address.

Student Name

Grade

School

is / is not being recommended to participate in the Savannah State University Upward Bound Program.

Student's grade point average:

High School Curriculum:

Does the student intend to pursue post-secondary education?

Yes

If no, why?

Intellectual ability and achievement:

How would you rate the student's academic ability and motivation?

Poor

Below Average Average

Academic Ability

1

2

3

Motivation

1

2

3

School Attendance:

Regular

Irregular

Has the student had any social, physical (health), or psychological problems?

If yes, please explain.

No

Above Average 4

4

Yes

No

Do you foresee any problems the student may have in dormitory living?

Yes

No

If yes, please explain.

Please give specific reason for recommending this student and provide any additional information which will assist us in assessing the student's personal and academic qualities as a potential participant.

Teacher Signature Subject you teach student

Date Telephone

- 6 -

Upward Bound

Dear Parent/Student: A completed application consists of the following: The Upward Bound Application with all pages completed The Student Essay (handwritten in blue or black ink) Eighth grade GMAS test scores Eighth grade report card Most recent report card Official Transcript from the current school including all standardized test scores Current year tax return ( a complete copy) Immunization record (shot record)

YOU MUST HAVE THESE ITEMS ON FILE TO HAVE YOUR APPLICATION EVALUATED. Once your application is evaluated, you will be contacted regarding the status of eligibility. You will be informed in writing of our final decision. It is important you provide the correct mailing address and telephone numbers, therefore, any changes in the information submitted on the application while in the evaluation phase should be reported as soon as possible. If you have any questions please do not hesitate to contact the office.

Sincerely,

Bobby E. Roberts, Jr. Director

Box 20488 | 3219 College Street | Whiting Hall | Savannah, Georgia 31404 | p.912.358.3477 | f.912.358.3687 | savannahstate.edu

A unit of the University System of Georgia ~ an equal opportunity/affirmative action employer.

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