WOSC UPWARD BOUND
Dear Parent/Guardian:
Your son/daughter has shown interest in the TRIO Upward Bound Program at Western Oklahoma State College. The WOSC Upward Bound Program is a federally funded program designed to assist high school students in their preparation for success in high school and college. Program services are available to eligible students at no financial cost to the student or families. Your son/daughter will receive payment for participation in the program according to the Upward Bound Handbook. All information received in the WOSC Upward Bound office is confidential and used for record keeping purposes only.
Attached information includes the application and all required paperwork. All paperwork must be completely filled out and returned to the office either by mail, in person, or to the school counselor. Applications are due no later than September 11th, 2017. If you plan to mail the application, please send it to WOSC Upward Bound Program, 2801 North Main, Altus, OK 73521.
As part of our selection process, we arrange to meet with the student and their parent/guardian. During the meeting, more information is provided about the program and any questions will be answered. Once we receive your child’s application and required paperwork, we will contact you to arrange an interview. A completed application allows the staff to process the application more rapidly.
If you have any questions, please call the WOSC Upward Bound office at 580.477.7760 or send an email to the following email address: . Feel free to text if you prefer that method of communication, my cell number is 580-471-7177. We appreciate your interest and look forward to meeting with you.
Terri Pearson,
Upward Bound Director
CHECKLIST OF REQUIRED PAPERWORK FOR A COMPLETED APPLICATION
______ A completed 4 page Upward Bound application with required signatures.
______A copy of the 2016 taxes that claimed the potential participant as a dependent. Please only submit the pages that contains the following information from the taxes: 1. Gross Income, 2. Taxable income, 3. List of dependents which includes the student applying for the program, 4. Signature page (taxes must be signed by at least one parent/guardian).
______A copy of the student’s most recent school transcript and any grade report since the most recent school transcript was released.
______A copy of the students’s End of Year Instructions Test Scores to include 7th and 8th grade test scores.
______Act Explore test results.
______Completed referral letter from a teacher or counselor.
Please be expecting a phone call, letter, or email from the program to schedule an individual parent/student meeting to discuss the program.
If you have any questions, please call me at 580.477.7760 or email me at
WOSC UPWARD BOUND APPLICATION
STUDENT INFORMATION:
Student Full Name: ______Date of Birth: ______
Mailing Address: ______Social Security Number: ______
Primary Language Spoken At Home: ______Age: ______
Limited English Proficiency (Yes or No): ______Male or Female: ______
Student Email Address: ______Student Cell Phone Number: ______
U.S. Citizen (Yes or No): ______College Path in High School (Yes or No) ______
Registration Number if not a U.S. Citizen: ______
RACE/ETHNIC GROUPS:
Black/African American: ______Asian: ______White: ______
American Indian/Alaskan Native: ______Native Hawaiian/Other Pacific Islander: ______
Hispanic/Latino: ______(If you select Hispanic/Latino, you must also select another race/ethnic group)
HIGH SCHOOL AND COLLEGE INFORMATION:
Name of High School: ______2017-18 Grade Level: ______
College/University You Plan To Attend After High School: ______
Occupational Goals: ______
HIGH SCHOOL COUNSELOR INFORMATION:
Student Enrolled On College Path: _____Yes _____ No Student Completed OK Promise: ____Yes ____No
Does Student Have an IEP: ______Yes _____ No If so, please list: ______
The Student is considered a Disconnected Youth: ____ Yes _____No GPA: ______
Counselor Signature: ______
PARENT/GUARDIAN INFORMATION:
Name of Parents/Guardians: ______Relationship: ______
Cell Phone Number: ______Work Phone Number: ______
Email Address: ______Occupation: ______
List All Individuals Living in the Home: ______
______
1. Has the student’s biological/adopted mother or father graduated from a four year college/university with a Bachelor’s Degree: ______Yes ______No
Parent/Guardian Signature: ______
2. Does your child have any physical and/or emotional condition? ______Yes _____ No
Please provide explanation of the condition. ______
______
______
2016 INCOME TAX INFORMATION: Please fill in the information below to include signature & date. A copy of the 2016 taxes MUST be submitted with the application.
2016 Gross Income: / 2016 Taxable Income: / Number of Dependents:The taxes provided only needs to include the information listed above plus the signature page of the taxes. The child applying for the program must be included as a dependent on the taxes.
By signing and dating this section of the application, the information I provided above is correct and accurate to the best of my knowledge. Parent/Guardian Sigature: ______Date: ______
DID NOT FILE TAXES: Please fill in the information below to include signature and date.
2016 Gross Income: / 2016 Taxable Income: / Number of Dependents:The income reported above must include all wages such as: SSA/SSI, VA/GI Bill, Retirement Pension, Food Stamp, etc.
__ Yes __ No The child applying for the program was not claimed as a dependent on any other persons 2016 taxes.
By signing and dating this section of the application, the information I provided above is correct and accurate to the best of my knowledge. Parent/Guardian Sigature: ______Date: ______
PARENT/GUARDIAN EXPECTATIONS:
One of the major goals of the Upward Bound Program is to encourage parental support and participation in their child’s development.
1. You are willing to be involved in the Upward Bound Parental Activities? ______Yes ______No
2. You are willing to meet with the Upward Bound staff and attend required meetings? _____ Yes _____ No
3. You will contact the Upward Bound staff when you have questions or concerns? ______Yes ______No
PARTICIPANT/STUDENT EXPECTATIONS:
1. If selected as a participant in the WOSC Upward Bound Program, I understand I am expected to participate from the time selected until I graduate high school to include every summer sessions and all activities.
2. My behavior will reflect positively on my family, community, school, the Upward Bound program, and myself.
3. I will not use alcohol or drugs not prescribed by my physician.
4. I will abide by the rules and regulations set forth in the Upward Bound policy.
PERMISSION/CONSENT FOR ALL REQUIRED RECORDS:
1. I give the WOSC Upward Bound Program my permission to receive copies of all my educational records and any other materials necessary for participation in the program.
2. I give my permission to request and receive all academic and financial aid records from any postsecondary institutions in order to track my college progress for at least six years after high school graduation.
3. I understand all records will be kept in confidence and in accordance with the Privacy Act of 1974.
Parent/Guardian’s Signature: ______Date: ______
Student’s Signature: ______Date: ______
STUDENT NEEDS ASSESSMENT
The survey must be completed honestly so the program can meet your needs. Your answers will be kept confidential.
ACADEMIC NEEDS:
Strong Need / Some Need / No Need1. / Need assistance on how to complete and turn in school assignments.
2. / How to improve my grades in school.
3. / Develop skills on how to take tests better and to reduce test anxiety.
4. / Develop skills to be better organized with my time, activities, and to be more responsible.
5. / Need more information on high school requirements for college.
6. / How to improve listening skills in class and ask more questions.
7. / Develop skills to relate and communicate better with my teachers.
8. / Need assistance on how to identify, set, and evaluate future goals.
My academic goal is:
PERSONAL NEEDS:
Strong Need / Some Need / No Need1. / Assistance on how to improve my relationship with parents and other adults.
2. / Develop skills on how to positively resolve conflict.
3. / Accept my physical appearance.
4. / How my self-esteem affects my behavior.
5. / How to get along better with my peers.
6. / Develop skills to accept people who are different from me.
7. / Information on the use/abuse of drugs and alcohol.
8. / To accept greater responsibility for my actions.
9. / Assistance with developing trust in relationships.
My personal goal is:
CAREER AND POSTSECONDARY NEEDS:
Strong Need / Some Need / No Need1. / How to explore a variety of career opportunities.
2. / Learn more about job applications, resumes, and interviews.
3. / Learn more about the postsecondary admissions process.
4. / Learn how to prepare for college entrance exams for example: ACT Test.
5. / Learn how to write college scholarships.
6. / How to select college classes.
7. / Learn the cost to attend college and how to pay for college.
8. / Learn what the FAFSA form is and how to fill out the form.
List the college you plan to attend and why:
Student Questionnaire
The Student Questionnaire must be completely answered; please write legibly. If you need additional space to completely answer the question; you may use another sheet of paper.
1. / What do you think is the purpose of the Upward Bound Program?2. / How do you expect the Program to assist you with your needs?
3. / What can you contribute to the Upward Bound Program?
4. / What do you think will be expected of you as an Upward Bound student?
5. / List the school subjects you excel in? Why?
6. / List the school subjects you have difficulties in? Why?
7. / Write a paragraph describing your educational and career goals and how you plan to achieve those goals over the next 10 years.
Mailing Address: Contact Information:
WOSC Upward Bound Program Office Phone Number: 580.477.7760
2801 North Main Fax Number: 508.477.7732
Altus, OK 73521 Email Address:
Western Oklahoma State College Upward Bound Program
Student Referral/Recommendation Form
This form must be completed by a high school counselor, principal, or a teacher who taught the student and knows the student well.
Student’s Name: ______Name of High School: ______
Name of Person Providing the Referral: ______
Work Phone Number: ______Email Address: ______
Relationship to the Student: ______
______
Please state frankly your evaluation of this student’s ability to benefit from the WOSC Upward Bound Program. The purpose of the program is to generate the academic and motivational skills necessary for college success. Participants must possess the ability to pursue and achieve at least a bachelor’s degree. The student must have a need for the services provided by the WOSC Upward Bound Program.
1. List specific academic needs of improvement:
______
2. Identify specific motivational areas of improvement:
______
3. Identify specific social/personal problems such as: low self-esteem, interpersonal relationships, home life, etc.
______
4. Provide any additional information or comments to assist us in providing better services to this student.
______
5. Does the student have an IEP or a learning disability? ______Yes ______No
If so, please provide detail information such as subject, dyslexic, etc.
______
Referral Signature: ______Date: ______
Mailing Address: Contact Information:
WOSC Upward Bound Program Office Phone Number: 580.477.7760
2801 North Main Fax Number: 508.477.7732
Altus, OK 73521 Email Address: