West Virginia State University
Pre-college Programs
The Upward Bound program works with students from the end of their 8 th grade year throughout
high school to prepare them to be the first in their families to attend college. Students are
engaged in a rigorous course curriculum that is designed to prepare them to compete on a global
stage. In addition, the Upward Bound Math-Science program emphasizes the STEM (Science,
Technology, Engineering, and Math) disciplines by helping students recognize and develop their
potential to excel in math and science and to encourage them to pursue college degrees in math
and science, and ultimately careers in the math and science profession.
Upward Bound Math-Science and Upward Bound Classic programs are college preparatory
programs designed to strengthen and enhance the critical thinking, scientific, and analytical skills
of high school students and are funded by grants through the U.S. Department of education.
Through group research, supplemental classes, field trips, and recreation, these programs help
students increase skills, motivation and research background necessary for successful entry into
college-level programs.
Academic-Year Support: Students receive year-round academic support through Saturday
Academic Sessions, after school weekly tutoring sessions, and assistance with preparation for
standardized exams. In addition, participants have the opportunity to earn a $120 stipend each
quarter throughout the academic year.
Summer Academy: Participants attend a mandatory six-week Summer Academy on the campus of
West Virginia State University and then enjoy a out-of-state trip. Program components include
coursework in English, Math, Science, Computer Technology, and individualized research in
addition to educational activities. Activities and services are provided at no cost to students and all
costs for the summer session including, books, supplies, room and board are free. Students will
also receive a monetary stipend of $90 for the Summer Academy.
Bridge Component: Participants who consistently meet project goals and attend summer sessions
will become eligible to apply for the Bridge Scholarship. Students who receive this scholarship
may take up to six credits of college coursework at WVSU in the summer immediate after their
senior year.
West Virginia State University
UPWARD BOUND PROGRAMS
PO Box 1000, Sullivan Hall 223 East, Institute, West Virginia 25112
Phone: (304) 766-3120 or Fax: (304) 766-5122
Upward Bound and Upward Bound Math-Science are federally funded TRIO programs.
WVSU Upward Bound Math-Science & Upward Bound Classic
P.O. Box 1000, Sullivan Hall 223, Institute, WV 25112
Phone: 304.766.3086 Fax: 304.766.5122
TRiO
Applicant Information & Assessment
Student Last Name:
First Name:
Social Security #:
Date of Birth:
Middle:
Email Address:
Current School:
Current Grade Level:
 8th
 9th
School ID #:
 10th
Mailing Address: Street and Apt. No.
 11th
 12th
Citizenship:  United States Citizen or
 Permanent Resident
City:
State:
Home Phone Number:
Age:
Zip:
Cell Phone Number:
Gender:
 Male
Have you had any legal interactions with the Department of Juvenile Services?
 Female
 Yes
 No
Ethnic Background:
 Hispanic
 White
 African American/Black
 Other
What are your favorite school subjects?
What classes (if any) do you think that you will need tutoring in?
What do you plan to do immediately after graduating from high school
 College  Work
What best describe the field or career you are interested in pursuing?
 Computers  Teaching
 Forensics
 Business
 Robotic Technologist  Linguistics
 Nurse
 Engineering
 Military
 Counselor
 Writer
 Chemistry  Lawyer
 Criminologist
 Don’t know
 History
 Doctor  Veterinarian Science
 Architect
 Undecided
 Other _____________________________________________________________
Please indicate the areas that you feel you would like to improve.
 Reading
 Public Speaking
 English proficiency
 Writing
 Interpersonal/Group Relations
 Achievement test scores
 Math
 Self-esteem and/or social skills
 Public Speaking
 Natural Sciences
 Study Skills
 Career goals
 Grade Point Average
 Other (specify)______________________
WVSU Upward Bound Math Science & Upward Bound Classic
 Record & School Release Form
Student Last Name:_________________________ First Name: ______________________________________ Middle: ___________________
Date of Birth: ___________________________________
Social Security: _____________________________________________
RELEASE OF ACADEMIC RECORDS
I authorize and give permission to the West Virginia State University Upward Bound Math Science, Classic
Upward Bound staff to access and/or receive copies of my academic transcripts, grade reports, report
cards, WESTEST scores, attendance reports, test results and any information needed to monitor my
academic progress. I also grant the Upward Bound Math Science and/or Classic Upward Bound staff
permission to speak with teachers, instructors, counselors and other school administrators at my child’s
school in order to obtain and exchange information as part of the services provided by the Upward Bound
programs. I understand that the United States Department of Education requires the West Virginia State
University Upward Bound Programs to report on my academic progress through either my graduation from
college or for at least six years after my high school graduation.
I understand that the U.S. Department of Education funds the Upward Bound Math Science and the Classic Upward
Bound Program and will use these records to provide academic advisement, follow-up and tracking. I also understand
that the Privacy Act protects this information and that these records will be handled in a confidential manner and that
they will be made available only to program staff and representatives from Federal and State Departments of Education.
Student Signature __________________________________________
Date ______________
Parent/Guardian Signature ____________________________________
Date ______________
I, as the parent or guardian of an Upward Bound Program participant, authorize the release of the information
described above (including via fax transmittal) on behalf of my minor child.
A photocopy of this record release form should be accepted as an original and the date
signed has no bearing to the date that the West Virginia State University Upward Bound
Math Science or the Classic Upward Bound Program or its staff requests the information.
WVSU Upward Bound Math Science & Upward Bound Classic
School Counselor Assessment Form
(To be completed by school counselor)
Student Last Name:________________________
First Name: _____________________________
What is the student’s current OVERALL GPA: _________
Middle: ______________
PSAT: Verbal _________ Written _________ Math ____________
COUNSELOR PLEASE ATTACH THE STUDENT RECORD AND TRANSCRIPT (beginning with 6th grade, if possible) INCLUDE ALL AVAILABLE TEST
SCORES AND a copy of the MOST CURRENT REPORT CARD
Please indicate the student’s WESTEST Achievement for the following:
Class Level
8th grade
Math
8th grade
Reading
9th grade
Math
9th grade
Reading
10th grade
Reading
10th grade
Math
Distinguished
Above Mastery
Mastery
Partial Master
Novice
Student did not take the assessment
Which of the following best describes this student's curriculum or pathway?
 Professional
 Skilled
 Entry
What is the student’s cluster? ____________________________ Major? ____________________________
How would you rate this student's attendance?
 Excellent
 Good
 Fair
Has this student ever been subject to school disciplinary action or suspension? No
 Poor
Yes Don’t know
Students selected for the Upward Bound Programs must demonstrate a need for services we provide. How would you categorize this student’s need?
Please check all that apply.





Need to improve GPA
Need to improve test scores
Need to develop stronger educational aspirations
Need for additional opportunities, support and/or guidance to take
challenging courses
Need to develop career goals




Predominately low-income community
Rural isolation
Interest in careers in Math and/or Science
Limited proficiency in English

Need to increase confidence or self-esteem
Please add additional comments on motivation, behavior, personality, strengths or weaknesses that you feel will help us in evaluating this student’s application. Also
indicate any academic, social support, special services, or IEP that this student is receiving. If this is the case, sometimes a short description of the situation may be helpful.
If discretion is necessary, please identify the information in person or on the telephone.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
 Counselor’s Signature: ______________________________
Print Name: ___________________________
School: _____________________________________
Date: _____________________________
WVSU Upward Bound Math Science & Upward Bound Classic
 Student's Personal Statement & Essay
Student Last Name:_________________________ First Name: ______________________________________ Middle: ___________________
1.
Please write an essay as to why you should be selected for the Upward Bound Programs at West Virginia State University. In this essay include
what Upward Bound Math Science or Classic Upward Bound can do for you, and what contributions you can make to this program.
Please organize your thoughts and use correct spelling, grammar, and punctuation.
2. Please provide a short description of yourself including your academic interests and your educational and career goals.
WVSU Upward Bound Math Science & Upward Bound Classic
 Family & Income Information
(To Be Completed by Parent/Guardian) - - THIS SECTION MAY BE MAILED IN SEPARATELY BY PARENT OR GUARDIAN
Student Last Name:_________________________
First Name: ______________________________________
Who does the student currently live with?
 Mother
 Father
Is the applicant a foster child or a ward of the court?
No
Yes
 Both Parents
Middle: _______________
 Guardian
Caseworker’s Name and Phone number: ___________________________________________________________________________
MOTHER/FEMALE GUARDIAN
Name:
____________________________________ Home/cell phone number: _______________ ____________________
Address: _____________________________ City: _____________________ State: ________________ Zip: __________________
Employer ______________________________________ Occupation____________________________________________________
Please check the highest level of education you have completed:  High school
 Some college  Four-year college degree
FATHER/MALE GUARDIAN
Name: __________________________________________ Home/cell phone number: __________________________________
Address: _____________________________ City: _____________________ State: ________________ Zip: __________________
Employer ______________________________________ Occupation____________________________________________________
Please check the highest level of education you have completed:  High school
Name (Last, First) List everyone in the Household. Attach a
separate sheet if needed.
 Some college  Four-year college degree
Relationship to Applicant
Age
School/ Occupation
1.
2.
3.
4.
5.
6.
The financial information requested below is required by the US Department of Education to determine your son/daughter’s eligibility for Upward Bound. Taxable
income is located on the second page of your 1040 tax return.
Yearly Taxable Income: $__________________
Child Support: $__________________
TANF: $__________________
Social Security: $__________________
V. A. Benefits: $__________________
Retirement: $__________________
Unemployment: $__________________
Other: $__________________
The Upward Bound Programs are funded by the U.S. Department of Education and are intended to serve either first-generation or low-income students who want to go to college. We
base eligibility on 'taxable' income. You must submit a copy of your signed income tax form for last year OR If you did not file income tax, please submit document(s) to verify
total income from AFDC, Social Security, Unemployment, Disability, Veterans Benefits, or other income.
I certify that the above information is true to the best of my knowledge.
 Parent/Guardian Signature: ______________________________
Date: ______________________
WVSU Upward Bound Math Science & Upward Bound Classic
 Consent, Liability Release Form
Student Last Name:_________________________
First Name: ______________________________________
Middle: _______________
In consideration for being accepted by West Virginia State University for participation in the Upward Bound Math Science Program and/or Classic
Upward Bound program, we (I), being 21 years of age or older, do for ourselves (myself) (and on behalf of my child) do hereby release, forever
discharge and agree to hold harmless West Virginia State University and the West Virginia State University Upward Bound Programs and the staff
thereof from any and all liability, claims or demands for personal injury, sickness, or death, as well as property damage and expenses, of any nature
whatsoever which may be incurred by the undersigned and the child that may occur while said child is participating in the above described program.
Furthermore, we (I) and on behalf of our (my) child hereby assume all risk of personal injury, sickness, death, damage and expense as a result of
participation in recreation and work activities involved therein.
Further, authorization and permission is hereby given to said program to furnish any necessary transportation, food and lodging for this
participant.
The undersigned further hereby agree to hold harmless and indemnify said university, its administrators, and employees, for any liability sustained
by said initiative as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant hereto. (If the
participant has not attained the age of 21 years): We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission
for him (her) to participate fully in said program, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby
authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical
bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby
assume all transportation costs.
(Type or print name of participant) (Only participant need sign if 21 years of age or older. If under 21, both parents must sign)
 Student Signature __________________________________________________
Date _____________________
 Parent/Guardian Signature ___________________________________________
Date _____________________
 Parent/Guardian Signature ___________________________________________
Date _____________________
 Publicity Release Form
Upward Bound Math Science, Classic Upward Bound or West Virginia State University staff may include my name, statements or photo in
publications including brochures, recruiting materials, web sites, press releases and other publications which feature the Upward Bound programs or
highlight participant’s achievements and accomplishments.
 Student Signature __________________________________________
Date ______________
 Parent/Guardian Signature ___________________________________
Date ______________
WVSU Upward Bound Math Science & Upward Bound Classic
 Medical Authorization Form
Throughout the year, we take our students on a variety of field trips. It is necessary that we have an accurate medical history in the event that emergency treatment is
required. All information is confidential. Any student without a completed and signed Medical Authorization Form will not be allowed to participate in field trips.
Student Last Name:
First Name:
Social Security #:
Date of Birth:
Middle:
Mailing Address: Street and Apt. No.
City:
State: WV
Zip:
Home Phone Number:
Parent Cell Phone Number:
Emergency Contact Name and Phone # if unable to contact parent:
Grand parent or closest relative name and phone:
Medical Insurance Information
Policy Holder’s Name:______________________________________ Policy#:___________________________________________
Insurance Company Name:__________________________________ Group #:___________________________________________
Physician’s Name:_________________________________________
Physician Phone #:___________________________________
Medical History of Student
Mark all items [yes] or [no] - Provide detail if answer is [yes]
Diabetes
Food Allergy
Hearing Defects
Asthma
Currently Under doctor’s care
yes
yes
yes
yes
yes
no
no
no
no
no
Date of last physical _____________________
Drug Allergy
Insect Bite Allergy
Convulsions/Epilepsy
Currently taking medication
Physical restrictions
yes
yes
yes
yes
yes
no
no
no
no
no
Date of last tetanus shot __________________
If currently taking medication indicate type and reason: _________________________________________________________
List details to items marked [yes]; __________________________________________________________________________
_____________________________________________________________________________________________________
I understand that should a health emergency arise, I will be notified as soon as possible and medical treatment as deemed necessary by competent
medical personnel is authorized. Other than medical emergency, I authorize the University to examine and treat my child in the same way that West
Virginia State University students are treated with notification of parents being dependent on the judgment of the physician. In addition, I agree to
indemnify and save and hold harmless West Virginia State University, its officers, agents and employees from and against any and all claims and
liabilities which may arise out of or result from or be in any way connected directly or indirectly while participating in the program.
 Student Signature __________________________________________
Date ______________
 Parent/Guardian Signature ___________________________________
Date ______________
WVSU Upward Bound Math Science & Upward Bound Classic
Mathematics Teacher Assessment
Dear Teacher:
This student is applying for admission into an Upward Bound Program at West Virginia State University. Your assessment of this student is an integral
element in the selection process. Please fax the completed Recommendation Form to (304) 766-5122. You may also return the completed
Recommendation Form to the student in a sealed envelope to submit with his/her completed student application. Should you have any questions or
concerns, please feel free to contact us at (304) 766-3085 or (304) 766-5142.
Student Name
School _______________________________________________
Class/Course Subject name: __________________________________________________________________________________
Please place an "x" in the appropriate box for each characteristic listed below:
Please evaluate this student as it relates to academic strengths and weaknesses, potential for growth, behavior in class, level of
motivation, quality of work, and achievement.
 Demonstrates an active interest in learning
 Is cooperative in academic/social settings
 Displays citizenship and leadership skills
 Works up to academic potential in your class
 Attends class regularly and on time
 Actively participates in class/group discussions
 Completes all or 90% of assignments
 Comes to class prepared to work
Students selected for the Upward Bound Programs must demonstrate a need for services we provide. How would you categorize this
student’s need? Please check all that apply.




Need to improve GPA
Need to increase confidence or self-esteem
Need to develop stronger educational aspirations
Need for additional opportunities, support and/or guidance to
take challenging courses
 Need to develop career goals




Predominately low-income community
Rural isolation
Interest in careers in Math and/or Science
Limited proficiency in English
 Need to improve test scores
Additional comments on motivation, behavior, personality, strengths or weaknesses that you feel will help us in evaluating this student’s application:
Teacher Name: ______________________________________________________
Course Name: ___________________________________
Email: ______________________________________________________________ Student’s grade in this course is: ____________________
West Virginia State University Upward Bound Math/Science Program
English or Science Teacher Assessment
Dear Teacher:
This student is applying for admission into an Upward Bound Program at West Virginia State University. Your assessment of this student is an integral
element in the selection process. Please fax the completed Recommendation Form to (304) 766-5122. You may also return the completed
Recommendation Form to the student in a sealed envelope to submit with his/her completed student application. Should you have any questions or
concerns, please feel free to contact us at (304) 766-3085 or (304) 766-5142.
Student Name
School _______________________________________________
Class/Course Subject name: __________________________________________________________________________________
Please place an "x" in the appropriate box for each characteristic listed below:
Please evaluate this student as it relates to academic strengths and weaknesses, potential for growth, behavior in class, level of
motivation, quality of work, and achievement.
 Demonstrates an active interest in learning
 Is cooperative in academic/social settings
 Displays citizenship and leadership skills
 Works up to academic potential in your class
 Attends class regularly and on time
 Actively participates in class/group discussions
 Completes all or 90% of assignments
 Comes to class prepared to work
Students selected for the Upward Bound Programs must demonstrate a need for services we provide. How would you categorize this
student’s need? Please check all that apply.




Need to improve GPA
Need to increase confidence or self-esteem
Need to develop stronger educational aspirations
Need for additional opportunities, support and/or guidance to
take challenging courses
 Need to develop career goals




Predominately low-income community
Rural isolation
Interest in careers in Math and/or Science
Limited proficiency in English
 Need to improve test scores
Additional comments on motivation, behavior, personality, strengths or weaknesses that you feel will help us in evaluating this student’s application:
Teacher Name: ______________________________________________________
Course Name: ___________________________________
Email: ______________________________________________________________ Student’s grade in this course is: ____________________