Northeastern Illinois University

Fall Tutoring Program

Saturday Institute Program

Summer Voyage Program

 

 

 

 

 

 

 

 

 

 

 

CHICAGO TEACHERS CENTER

770 NORTH HALSTED, 4TH FLOOR

CHICAGO, ILLINOIS  60622

OFFICE (312) 563-7107

FAX (312) 563-7010

 

 

 

 

 

 

 

Dear Prospective Upward Bound Participant:

 

The instructions below were prepared to assist you and your parents or guardians complete the Upward Bound application.  Please read them thoroughly before beginning the application. Students with incomplete applications and/or missing documents will not be allowed to receive Upward Bound services.  Except where signatures are required, all information should be printed in black or blue ink.

 

 

1.      Page Two.  Complete all the information we ask about you. It is very important that you give us your social security number and high school identification number.  You must also provide a photocopy of your social security card or alien registration documents.

 

2.      Page Three.  Compose an essay that responds to BOTH questions we ask you. If the personal statement is undone or incomplete, we will hand back your application, and your admission will be delayed. You may wish to do a draft on scratch paper before writing in the space provided on the application. Please PRINT your personal statement.

 

3.      Page Four.  Have your parents or guardians complete this page.  It is important to get a work telephone number (if available) in case of emergencies.

 

4.      Page Five.  Have your parents or guardians complete this. It is important that they read this page carefully so that an acceptable income verification document is submitted.  Please note that check stubs and W-2 forms are NOT acceptable as proof of household income. Tax forms (IRS 1040) must include taxable income as well as the name, and social security number of the student applying to Upward Bound.

 

5.      Page Six.  You and your parents or guardians should carefully read this page and sign on the appropriate lines.

 

6.      Page Seven. This page should be completed by a teacher or counselor who knows you well as a person and/or who is familiar with your academic work. If the recommendation is not completed, we will hand back your application, and your admission will be delayed.

 

7.      If you are an incoming 9th grader, please also submit a copy of your final report card from 8th grade and a copy of your final ITBS (Iowa Test) scores.

 

8.      If you are applying for admission to Summer Voyage, the Upward Bound summer program, be sure to complete the one page summer registration form and leave it attached to the application.

 

 

If you have questions, please call me at (312) 563-7146

 

Sincerely,

 

 

Troy A. Norman

Assistant Director

Project Upward Bound

 

I.                   GENERAL INFORMATION                     

 

Today’s Date:

 

 

Full Name:

Date of Birth:

           

Address:

Zip:

 

Phone:

 

Gender:

Male ¨

Female ¨

 

Name of High School:

 

 

 

Present Grade:

¨  9th

¨  10th

¨  11th

¨  12th

 

 

 

 

 

 

Dear Applicant:

You must answer the questions marked with a (*). Your application is not complete unless those questions have been answered. If you are a U.S. citizen, you do not have to provide an Alien Registration Number.  Also, please include a photocopy of your Social Security Card or Alien Registration documents.

 

 

Division Number

 

 

High School ID Number

 

 

*Social Security Number

 

           

*Are you a U.S. Citizen?

¨ Yes

¨  No

 

*If not, provide your Alien Registration Number A-________________________________________   

     

                                            

Which one of the following best describes your ethnicity or race: 

 

¨

American Indian/Alaskan Native

¨

Native Hawaiian/Other Pacific Islander

¨

Asian

¨

White

¨

Black/African American

¨

Other

¨

Hispanic/Latino

 

 

 

Further specification:  ___________________________________________________________________

 

 

Mother’s Name:

 

 

Father’s Name:

 

 

Guardian’s Name:

 

 

Student Lives With:

¨  Mother

 ¨ Father

¨  Stepmother

 ¨ Stepfather

 

¨  Other  (Specify: ___________________________________________)

           


 

                                                                                               

II.        EDUCATIONAL HISTORY

 

 

What is your favorite class in school?                                              

 

 

 

 

What is your least favorite class in school?

 

 

 

 

What do you plan to do after high school?

 

 

 

 

 

 

 

 

 

What are your career goals/interests?

 

 

 

 

 

 

 

 

Personal Statement:  Using at least one paragraph, describe yourself and explain why you want to be in Project Upward Bound.  (Use the back of this page if you need additional space.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III.       ELIGIBILITY INFORMATION  (To be completed by Parent(s)/Guardian(s))

 

 

A.        Female Guardian

 

Name

 

 

Relationship to student

 

 

Home Address

 

Zip

 

 

Home  Phone

 

Employed (circle one):

 

Yes

 

No

 

 

Occupation

 

Work Phone

 

 
Your Education

Less than high school   c

9 c

10 c

11 c

12 c

 

Years of college completed:

1 c

2 c

3 c

4 c

 

What degree(s) do you hold?

None  c

AA c

BA/BS c

Graduate/Professional c

 

 

B.         Male Guardian

 

Name

 

 

Relationship to student

 

 

Home Address

 

Zip

 

 

Home  Phone

 

Employed (circle one):

 

Yes

 

No

 

 

Occupation

 

Work Phone

 

 
Your Education

Less than high school   c

9 c

10 c

11 c

12 c

 

Years of college completed:

1 c

2 c

3 c

4 c

 

What degree(s) do you hold?

None  c

AA c

BA/BS c

Graduate/Professional c

Source(s) of Income (Check all that apply):

 

¨

Pay from Work

¨

Alimony/Child Support

¨

Veterans Benefits

¨

Welfare (AFDC and GA)

¨

Social Security

 

 

¨

Unemployment

¨

Other pension, retirement, etc.

 

 

 

 

 

VERY IMPORTANT! PLEASE READ THIS SECTION THOROUGHLY

 

Project Upward Bound receives its funding  from Congress as a result of the Higher Education Act of 1965. We must comply with the stipulations of the Higher Education Act as well as with regulations issued by the U.S. Department of Education, the office to which we directly report.  Because of this, we are mandated to request information that determines each applicant’s eligibility to receive our services.

 

Eligibility Criteria:

 

i) Only citizens of the United States and permanent resident aliens are eligible to participate in Upward Bound. Applicants must respond to the citizenship question on page 3 and provide a Social Security number and/or Alien Registration number and a copy of the Social Security card and/or Alien Registration document.

 

ii) Two-thirds of the students served by Upward Bound must be low-income as defined by the federal government; as well as, first-generation college bound. This means that neither of the student’s parents has earned a bachelor’s degree. The remaining one-third of the students we serve can meet either eligibility criterion. Proof-of-income documents must contain the names and social security numbers of the parents or guardians and all dependents, including the child applying to Upward Bound.  Acceptable proof-of-income documents include Medicaid cards and IRS Form 1040.  Check stubs and W-2 forms are not acceptable.  If the document you submit is an IRS 1040, it must show the amount of TAXABLE INCOME.  Please submit a copy of your documents because we will need to keep them in your child's permanent record.

 

 

Students are not officially enrolled and will not be allowed to receive program services until their eligibility has been verified.

 

If you need a question answered or would like more information, please contact the project director at 312-563-7107 or the assistant project director at 312-563-7146

 

 

 

 

 

IV.       PERMISSION FOR MEDICAL TREATMENT and RELEASE OF RECORDS 

 

 

I understand and consent to the following:

           

 

1.         I give permission for my child to participate in Project Upward Bound and for the program to secure her/his academic records each year that my child participates in the program.

 

2.         I authorize the Chicago Public Schools and its representatives to release my child's academic records and family's financial records to Northeastern Illinois University's Upward Bound project staff each year that my child participates in the program.

 

3.         I authorize Northeastern Illinois University's Project Upward Bound to provide medical services to my child if necessary.

           

 

PRINT your child's name here_____________________________________________________

 

All of the information I have provided in this application is true to the best of my knowledge.  Moreover, the documents I have submitted to verify my child's eligibility to participate in Project Upward Bound are authentic and accurately reflect my family's income at the time my child applied to the program.

 

 

Parent/Guardian Signature_______________________________________Date____________

 

 

 

I give the Chicago Public Schools and its representatives permission to release my academic records to the Northeastern Illinois University Upward Bound project each year that I participate in the program.

 

 

Student Signature_____________________________________Date____________

 

 

 

 

 

 

 

V.        RECOMMENDATION FORM

            (To be completed by a teacher or counselor familiar with the student)

 

            Candidate's Name_________________________________________

 

            Teacher/Counselor_________________________________________

 

            School_______________________________________________­­­­____

 

To the teacher/counselor:  The student named above is applying to Northeastern Illinois University's Project Upward Bound.  Since applications cannot be considered until we have received this form, both the student and Upward Bound staff would appreciate a prompt reply.  Thank you very much for your time and effort.

 

a)      In what capacity or context do you know or have you known this student?

 

 

b) How long have you known this student?

 

 

c) Please evaluate the student in the following categories. Check only ONE column per category.

 

                                   

 

 

Superior (4)

 

Above Average (3)

 

Average (2)

 

Below Average (1)

Academic Ability

 

 

 

 

Academic Achievement

 

 

 

 

Personal Qualities

 

 

 

 

 

d) Please check only ONE of the following:

 

I strongly recommend this student                           ¨

I recommend this student                                          ¨

I recommend this student with reservations                        ¨

I do not recommend this student                              ¨

 

e) We welcome any additional comments that you believe will help us.

 

 

Teacher/Counselor signature___________________________________Date______________

 

Return recommendation to student or UB staff member, or mail to Project Upward Bound, Chicago Teachers' Center, 770 N. Halsted, 4th Floor, Chicago, IL  60622.  If you have any questions, please call us at (312) 563-7107