Today’s Date_______________________ - UMES



UPWARD BOUND PROGRAM

UNIVERSITY OF MARYLAND EASTERN SHORE

TELEPHONE: (410) 651-6458

APPLICATION CHECKLIST

TO THE STUDENT APPLICANT:

THIS APPLICATION SHOULD BE COMPLETED BY YOU. HAVE YOUR PARENT OR GUARDIAN FILL IN THE INFORMATION PERTINENT TO THEM.

1. PLEASE CHECK OFF EACH ITEM UPON COMPLETION TO INSURE THAT YOU HAVE ANSWERED ALL QUESTIONS. ONLY COMPLETED APPLICATIONS WILL BE CONSIDERED FOR EVALUATION AND ADMISSION TO THE UMES UPWARD BOUND PROGRAM.

2. MAKE A COPY OF YOUR COMPLETED APPLICATION FOR YOUR PERSONAL RECORD.

3. YOUR APPLICATION CAN BE MAILED OR FAXED TO OUR OFFICE

APPLICATION INCLUDES:

PERSONAL INFORMATION

PARENT/GUARDIAN INFORMATION

COPY OF THE FEDERAL 1040/1040A TAX FORM OF THE PERSON WHO CLAIMS APPLICANT AS DEPENDENT

OR NOTARIZED AFFIDAVIT, GRANT OR BENEFITS LETTER

TEACHER’S EVALUATION AND COUNSELOR’S RECOMMENDATION

PERSONAL ESSAY

COPY OF CURRENT REPORT CARD AND UNOFFICIAL TRANSCRIPT WITH MSA, HSA SCORES

COPY OF SIGNED SOCIAL SECURITY CARD AND IMMUNIZATION RECORDS

UPWARD BOUND PROGRAM

UNIVERSITY OF MARYLAND EASTERN SHORE

TELEPHONE: (410) 651-6458

STUDENT APPLICATION

This application must be completed by parent(s)/guardian and student. The information on this form will be used to determine whether students are eligible for the Upward Bound. Incomplete applications will not be processed. Please mail pages 1& 2 to the Upward Bound Office.

STUDENT INFORMATION (Please Print or Type in Ink)

|Last Name |First Name |MI |SSN # |Present Grade |

| | | | | |

|Address |City |State |Zip Code |Age |Sex |

| | | | | |□ Female |

| | | | | |□ Male |

|Race: African American  Asian  Hispanic  Native American  Caucasian  Other ______________________________ |

|Home Telephone # |Student’s Cell # |Date of Birth |Guardian Information: Student lives with: |

| | |/ / | |

| | | |Mother □ Father □ Guardian(s) □ |

SCHOOL INFORMATION

|Name of School |Counselor’s Name |

| | |

|School Address |City |State |Zip Code |

| | | | |

|School Telephone # |Expected Date of Graduation |G.P.A. |Free Lunch  |

| | | |Reduced Lunch  |

|THE FOLLOWING MUST BE SUBMITTED WITH THIS APPLICATION: |

| |

|Teacher’s Evaluation and Counselor’s Recommendation |

| |

|Personal Essay |

| |

|Most Recent Report Card and an Unofficial Transcript including relevant standardized test scores (e.g. MSA, HSA) |

| |

|Social Security Card and immunization records |

| |

|Copy of most current Federal Income Tax Form (1040 tax form) or a copy of Grant or Benefits Letter (statement must be notarized) of the person who claims the |

|applicant as a dependent. |

PERSONAL ESSAY: (Please Type)

On a separate sheet of paper, please explain why you would like to participate in the Upward Bound Program (i.e. tell us about yourself, your future career plans, and how Upward Bound can help you reach your goal(s).

Please return to UMES Upward Bound Program, 30665 Student Services Center Lane, Princess Anne, MD 21853.

STUDENT APPLICATION continued

parent data

Student’s Name (Please type or print in ink)

___________________________________________________________________________________ Grade: 8th 9th 10th

Last First Middle

Financial Information: (To be completed by parent or guardian) In order to be eligible for the program, students must satisfy low-income criteria established by the U.S. Department of Education and/or meet first generation college student status.

|Mother/Female Guardian: Income and Occupation |Father/Male Guardian: Income and Occupation |

| | |

|Name: _______________________________________________________ |Name: __________________________________________________ |

| | |

|Title/Occupation: _____________________________________________ |Title/Occupation: _________________________________________ |

| | |

|Work Telephone #: ___________________________________________ |Work Telephone #:________________________________________ |

| | |

|Cell Phone # ________________________________________________ |Cell Phone # _____________________________________________ |

| | |

|Annual Gross Income $_______________________________________ |Annual Gross Income $____________________________________ |

| |

|Total number of persons living at Annual Total Family Gross Income: |

|home dependent on the income listed above: |

|(including parents) |

|First Generation Status Parent(s) Guardian(s) Education |First Generation Status Parent(s) Guardian(s) Education |

|Mother/Female Guardian: |Father/Male Guardian: |

|Graduated High School Earned Bachelor’s Degree |Graduated High School Earned Bachelor’s Degree |

|(earned a 4 year degree) |(earned a 4 year degree) |

| | |

|Yes  No  Yes  No  |Yes  No  Yes  No  |

| | |

|PARENT(S) GUARDIAN(S) PLEASE READ BELOW AND SIGN BELOW: |

| |

|In applying for a federally funded program, you should know that anyone making false statement or misrepresentation in establishing eligibility is subject to a |

|fine or imprisonment or both under provisions of the U.S. criminal code. |

|I certify the information provided is correct to the best of my knowledge |

|I will participate in all Upward Bound activities requiring my presence and promise to attend at least 2 parent meetings during the year. |

|I give consent for my child to use public and private transportation for off-campus activities. |

|I authorize my child’s high school to release grade reports, transcripts and any other pertinent material now and throughout the duration of high school to the |

|UMES Upward Bound Program. |

| |

|________________________________ __________________________________________ |

|Parent/Guardian (Print Name) Parent/Guardian Signature |

|Date |

UMES UPWARD BOUND PROGRAM

Counselor Recommendation

TO THE STUDENT: Fill in your name, circle grade level and give this form to your Guidance Counselor. Have your Guidance Counselor mail the form directly to the Upward Bound office. Please type or print in black ink.

______________________________________________ ___________________________________ GRADE: 8th 9th 10th

Student’s Name School

TO THE COUNSELOR: This student is applying for admission to the University of Maryland Eastern Shore Upward Bound Program. Please complete this form and attach a copy of their transcript, standardized test scores and most recent report card. Upward Bound is a federally funded program designed to prepare high school age students for college. Your honest assessment of this student will assist us in determining if this student would benefit from our services. Upward Bound seeks students who are motivated academically but need academic assistance.

NAME OF COUNSELOR COMPLETING FORM: __________________________________________________________________________

PHONE # _________________________________________

|YOU MUST return a copy of the student’s Official High School Transcript and/or most recent report card with this form. |

Please rate the student on the following characteristics:

5= Outstanding 4= Excellent 3= Good 2= Above Average 1= Average 0= Not Applicable

_______ Creativity ______ Self Confidence ______ Leadership Potential

_______ Interpersonal Skills w/Peers ______ Ability to cope with disappointment or failure ______ Willingness to accept responsibility

_______ Interpersonal skill with adults’ ______ Ability to set and achieve academic goals ______ Ability to learn new concepts

_______ Study habits ______ Self-initiative motivation ______ Independence

Academic Potential: Excellent  Good  Fair  Grade Average 

Motivation: High  Motivated when interested  Uninterested 

Home Climate: Positive Influence  Neutral  Negative Influence 

Disciplinary Action: Comment on any disciplinary action(s) at present school _________________________________________

______________________________________________________________________________________________________

Physical Disability: Yes No If yes, comment: _________________________________

Potential: Do you feel this student has the potential for being successful in a two or four-year college (even if presently not achieving)? Yes No

Recommendation: Do you recommend this student for the Upward Bound Program? Yes No

Please write a brief state of recommendation: __________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________ _________________________

Counselor’s Signature Date

Please return to UMES Upward Bound Program, 30665 Student Services Center Lane, Princess Anne, MD 21853.

PLEASE DO NOT RETURN TO THE STUDENT.

UMES UPWARD BOUND PROGRAM

Teacher Recommendation

TO THE STUDENT: Fill in your name, circle grade level and give this form to a teacher (English, Math, Science, Foreign Language, Social Studies). It is your responsibility to see that your teacher mails it directly to the Upward Bound Program or gives it to your guidance counselor for attachment counselor form. Please type or print in black ink.

______________________________________________ ___________________________________ GRADE: 8th 9th 10th

Student’s Name School

TO THE INSTRUCTOR: This student is applying for admission to the University of Maryland Eastern Shore Upward Bound Program. We ask for careful ratings and comments about his/her character and ability from an instructor who knows her/him well. Upward Bound is a federally funded program designed to prepare high school age students for college. Your honest assessment of this student will assist us in determining if this student would benefit from our services. Upward Bound seeks students who are motivated academically but need academic assistance.

NAME OF TEACHER COMPLETING FORM: __________________________________________________________________________

POSITION/SUBJECT ___________________________________________PHONE # _________________________________________

Please rate the applicant’s qualification by indication below:

A. Academic Performance Top 10% Top 20% Top 25% Under 25%

○ ○ ○ ○

B. Class Attendance & Punctuality Top 10% Top 20% Top 25% Under 25%

○ ○ ○ ○

C. Attitude Top 10% Top 20% Top 25% Under 25%

○ ○ ○ ○

D. Academic Potential Great Potential ○ Low Potential ○

Comments: ___________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

E. Has the student been attentive and cooperative in class: YES ○ No ○

F. Do you believe this student could successfully complete a postsecondary education if he/she received academic assistance while in high school?

YES ○ No ○

_________________________________________________________ ____________________________ ____________________________

Teacher’s Signature Title/Position Date

Please return to UMES Upward Bound Program, 30665 Student Services Center Lane, Princess Anne, MD 21853.

PLEASE DO NOT RETURN TO THE STUDENT.

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$

For Office Use Only

ꋨꌰꌲꌴꌸꌺꌾꍀꍄꍆꍊꍌꍘꍚꍜꍠꍢꎐꎒꎜꎞꎤꎦꎰꏘꠀꢨꨜ���틖틖틖틖싈싈뚾뚾龭튾邾皎^ᔯ轨홄ᘀ敨偿㔀脈⩂䌍ፊ伀Ɋ儀Ɋ尀脈䩞[?]䩡桰€唃Ĉᔝ褕ᘀ敨偿䈀പ䩃䩡桰€̚jᘀ敨偿唀Ĉ䡭Ѐ䡮Ѐࡵ[pic]ᘑ摨렸洀H渄H甄Ĉ̏jᘀ敨偿唀Ĉᘆ敨偿ᘊ敨偿　ቊ̓jᘀ敨偿　ቊ唀ĈᘆRecruitment status: □Accepted □Denied □Waiting List Letter mailed: _______________

Entry status: □ Low income & first generation □ First generation only □ Low income only

Target school: □ Crisfield High □ Washington High □ Parkside High □ Bennett High □ Wicomico High

Entry grade level □8 □9 □10 Grade level at beginning of AY □9 □10 □11

Recruited by: _____________________________________

DRE ______________ LOG___________________ ACA__________ FIN___________

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