Crowder College Upward Bound Programs

Application for Admission

Dear Applicant/Parent/Guardian,
The Crowder College Upward Bound and Upward Bound Math & Science staff would like to welcome you to
the application process. The Upward Bound Programs provide services at no cost to 300 freshmen,
sophomores, juniors, and seniors attending high schools in Barry, Barton, Bates, Cedar, Dade, Jasper,
Lawrence, McDonald, Newton, and Vernon counties. To qualify, applicants must meet only one of two criteria.
The applicant must either be a first generation college student (to be first generation, the applicant cannot
reside with a natural/adoptive parent who has a Bachelors degree or higher), or the applicant must meet an
income guideline (defined annually by the federal government). The programs objectives are to enhance
academic motivation and help students develop the skills necessary to successfully complete high
school and graduate from a program of postsecondary education.
Students participating in the program will attend three separate components. The program begins in the
Academic Year when participants receive academic assistance and guidance. Other services may include:
college visits, cultural and educational trips, computer literacy, academic and career assessment, ACT
readiness, student success workshops, and financial aid assistance. Closer to College (C2C) sessions meet
one Saturday per month. Participants from Barry, Dade, Jasper, Lawrence, McDonald, and Newton counties
meet on the Neosho Crowder College campus while those in Barton, Bates, Cedar, and Vernon counties meet
at the Nevada Crowder College campus. Participants work with C2C staff and instructors on the skills
necessary for entering college. Participants are rewarded for academic progress and may earn up to $30 per
month. Students can also earn a bonus up to $90, distributed at the end of summer, for attending all C2Cs.
Parents are also provided opportunities for educational, personal, and professional enrichment. Parent courses
may include financial planning, time management, coping with teens, stress management, career planning,
and chemical abuse.
The next component of the program is a six-week College Prep Academy (CPA) held during the summer
months. During this portion of the program, students live in the Crowder College dorms, Monday through
Friday, at the Neosho campus with other Upward Bound students. They take classes that will help prepare
them for their next year in school. In addition, the students spend three hours a day in a hands-on research
class which is designed to help explore different career fields. The College Prep Academy also implements
self-esteem and community-building activities that increase the chances of high school and college success.
Students who maintain a C average during the CPA can take a week-long trip to a major city in the United
States.
Once students have graduated high school, they will complete one more summer at the CPA, which is called
their Bridge summer. These students enroll in up to six college credit hours at Crowder with books and tuition
covered by the Upward Bound Programs. Bridge participants are provided all the privileges of the College Prep
Academy.
We encourage you to apply if you wish to successfully graduate from high school and obtain a four-year
college degree. Please carefully complete the entire application, paying specific attention to the checklist
included in the application packet. Good luck and we hope to see you in an interview!

Application Due September 19, 2014

(417)455-5688

Crowder College Upward Bound Programs

Application for Admission
Students: Please keep this checklist for future reference.
The following application packet must be completed in its entirety for us to consider you as an applicant for the
Crowder College Upward Bound or Upward Bound Math & Science program. The information requested is confidential,
and we assure you that it will remain so. Anyone in the UB/UBMS office is more than happy to answer any questions you
may have about the application or the program.
Qualifications
The applicant must be:
a current freshman or sophomore.

currently attending a high school in Barry, Barton, Bates, Cedar, Dade, Jasper, Lawrence, McDonald, Newton, or Vernon
counties.

a U.S. citizen or permanent resident.

a potential first generation college graduate and/or satisfy an income guideline. To be first generation, the applicant
cannot reside with a natural/adoptive parent who has a Bachelors degree. Income guidelines are predetermined by
the United States Department of Education and change annually.

able to attend 75% of Closer to College (C2C) sessions throughout the school year.

able to attend the six-week summer residence component.

committed to improving his/her high school grades.

planning to attend college full-time following high school graduation

Selection Process

Applications must be postmarked no later than Friday, September 19, 2014.

Interviews for qualified students will be scheduled at your school after the application deadline.

Notification of acceptance will occur by Friday, October 17, 2014.

Required orientations for successful applicants and their parents will be held as follows: Tuesday, October 21, 2014
for the Neosho region at the Neosho, Crowder College campus (Barry, Dade, Jasper, Lawrence, McDonald or Newton
counties) OR Thursday, October 23, 2014 for the Nevada region at the Nevada, Crowder College campus (Barton,
Bates, Cedar, or Vernon counties).
Parents, please plan to attend.
Checklist
Complete application for selection.
Complete short answer questions.
Complete financial form with student and parent/guardian signatures.
Submit recommendation form to instructor with the enclosed self-addressed envelope and make him/her aware of the
September 19th deadline.
Complete two (2) transcript release forms with student and parent signatures .
Any questions may be directed to:
Crowder College Upward Bound Programs
601 Laclede Avenue
Neosho, MO 64850
(417) 455-5688 email: upwardbound@crowder.edu

Application Due September 19, 2014

(417)455-5688

Crowder College Upward Bound Programs

Application for Admission

Name ________________________________________________________ SSN _______________________

First
M.I.
Last
Preferred name
Home Address _________________________________________________Todays Date _________________
City ____________________________________________ State ____________ ZIP Code ______________
Home Phone Number _______________________Email Address_____________________________________
Date of Birth __________________ Age _________ Marital Status __________ Gender: Male
High School ________________________________ Current Grade:

County ____________________________________ Year of Graduation:

10

Female

11

2016

2017

2018

Ethnic Background (optional; needed for federal reporting)

_____ Asian

_____ Hispanic or Latino

_____ Black or African American

_____ Native Hawaiian or other Pacific

_____ American Indian/Alaskan Native

Islander

_____ Native American

_____ More than one race

_____ White

_____ No response

Do you have a disabling condition?

Yes

No

Attach
Photo

Here
(Optional)

If yes, please list (optional; needed for federal reporting).

_________________________________________________________________________________________

With whom do you live? (Circle the appropriate relationship below each line.)
Name of Father/Step/Guardian/Other

Daytime Phone Number

Evening Phone Number

Name of Mother/Step/Guardian/Other

Daytime Phone Number

Evening Phone Number

Name of faculty member who is completing your evaluation form _________________________________

High School Phone Number ____________________________

Application Due September 19, 2014

(417)455-5688

Crowder College Upward Bound Programs

Application for Admission

Please list all math and science courses you have or will be taking between grades 7-12. This information is extremely important.

Math

Yr

Science

Yr

Please circle your level of interest in the following subjects with 1 being low and 4 being high.
Low
Biology:
1 2
Mathematics:
1 2
Foreign Lang: 1 2
History:
1 2
Business:
1 2

High
3
3
3
3
3

4
4
4
4
4

Chemistry:
Physics:
English/Lit:
Government:
Psychology:

Low
1 2
1 2
1 2
1 2
1 2

High
3
3
3
3
3

4
4
4
4
4

Low
Agriculture:
1 2
Speech/Debate: 1 2
Computer Sci. 1 2
Music/Art:
1 2
Geography:
1 2

3
3
3
3
3

High
4
4
4
4
4

Please list all classes you are currently taking.

Please list your extracurricular activities .

_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

Please select one choice below that applies to your personal education goals.
__
__
__
__
__
__
__

Less than a High School Diploma

High School Diploma or GED
Complete an Associates degree (2 yr.)
Complete a Bachelors degree (4 yr.)
Complete a Masters degree (5-6 yr.)
Complete a Ph.D., M.D., or law degree (8+ yr.)
I dont know what my goals are.

More specifically, my college and career goals include:

____________________________________________________________________________________________

____________________________________________________________________________________
____________________________________________________________________________________
Application Due September 19, 2014

(417)455-5688

Financial Information Form

Name ____________________________________ Phone ___________________________________
Are you a citizen or national of the United States? ________ or a permanent resident? _________
Are you currently in Foster Care?

Yes

No

Please check only one blank for father and one blank for mother:
Your natural/adoptive father:
__
__
__
__
__

Your natural/adoptive mother:

did not graduate from high school.

graduated from high school.
obtained an Associates degree (2 yr).
obtained a Bachelors degree (4 yr).
has a graduate degree or graduate hours.
(i.e. Masters or Doctorate degree)

Do you live with your natural/adoptive father?

Yes No

__
__
__
__
__

did not graduate from high school.

graduated from high school.
obtained an Associates degree (2 yr).
obtained a Bachelors degree (4 yr).
has a graduate degree or graduate hours.
(i.e. Masters or Doctorate degree)

Do you live with your natural/adoptive mother?

Yes No

Please complete the following from your parents 2013 federal income tax forms. If you are married, use your own tax
information. The following line numbers correspond to taxable income on the federal forms. Check only one box and fill in
the corresponding line to the right. THIS INFORMATION IS MANDATORY FOR THE APPLICANT TO BE CONSIDERED
FOR THE PROGRAM.
Did not file a 2012 federal income tax form. Household taxable income is $ _______________
Filed a 1040 form. Fill in the number from line 43.
$ _______________
Filed a 1040A form. Fill in the number from line 27.
$ _______________
Filed a 1040EZ form. Fill in the number from line 6.
$ _______________
How many people reside in the home? _________
I hereby certify that the above-stated is, to my knowledge, correct and true. I understand that upon acceptance into the
Upward Bound or Upward Bound Math/Science program, I may be asked to submit a copy of income documentation (e.g.
income tax form).

Students Signature

Parents Signature

For Office Use Only:

Inc ________ 1G _______ Staff Initials ________

Date

Please answer the following questions in 100 words or so, hand written and in your own words.
1) How would you compare your educational interests and goals with other students in your high school?

2) Tell us about a time when you went above and beyond what was expected of you either at school or
someplace else.

*Release of Student Information

STUDENT PORTION
There are two copies of this formplease complete the top portion only of both and return with application.

Return with completed application postmarked by September 19, 2014UB COPY

The top portion is to be completed by the student and parent/guardian.
Please return BOTH copies of this form with your application. Program staff will have the high school
portion completed.
Student Name ___________________________________________

Current Grade

10

11

High School __________________________________ SSN __________________________________

I hereby authorize my high school to release my official student information including transcripts, grades, test scores,
disciplinary records, and other information concerning my academic and personal well-being to the Crowder College Upward
Bound and Upward Bound Math/Science programs. I also authorize my high school to release official copies of any and/or
all of my report cards.
Students Signature

Parents Signature

Date

FOR HIGH SCHOOL USE ONLY

If the student is a current 10th or 11th grader, please complete the bottom portion of this form and attach an
official transcript.
If the student is a current 9th grader, please provide 8th grade transcripts and 8th grade State Standardized
Testing scores in English and Math.
Signature of person completing form ______________________________________________
Title _______________________________

Phone number _________________________________

Cum.GPA for last academic year completed:

Standardized Test/EOC:

________ on ________ scale.

Grade Level:_________

Scored proficient or above on State Standardized Testing

Math: Yes___ No___ R/LA: Yes___ No___

Does this student have any diagnosed learning disabilities? Yes_____ No_____
According to your records, has this student violated the Missouri Safe Schools Act? Yes____ No_____

*School Official: There are two copies of this form. Please retain one copy for your file. UB/UBMS staff will collect the other
copy at the scheduled interview day.

*Release of Student Information

STUDENT PORTION
There are two copies of this formplease complete the top portion only of both and return with application.

SCHOOL COPY
The top portion is to be completed by the student and parent/guardian.
Please return BOTH copies of this form with your application. Program staff will have the high school
portion completed.
Student Name ___________________________________________

Current Grade

10

11

High School __________________________________ SSN __________________________________

I hereby authorize my high school to release my official student information including transcripts, grades, test scores,
disciplinary records, and other information concerning my academic and personal well-being to the Crowder College Upward
Bound and Upward Bound Math/Science programs. I also authorize my high school to release official copies of any and/or
all of my report cards.
Students Signature

Parents Signature

Date

FOR HIGH SCHOOL USE ONLY

If the student is a current 10th or 11th grader, please complete the bottom portion of this form and attach an
official transcript.
If the student is a current 9th grader, please provide 8th grade transcripts and 8th grade State Standardized
Testing scores in Reading/Language Arts and Math.
Signature of person completing form ______________________________________________
Title _______________________________

Phone number _________________________________

Cum.GPA for last academic year completed:

Standardized Test/EOC:

________ on ________ scale.

Grade Level:_________

Scored proficient or above on State Standardized Testing

Math: Yes___ No___ R/LA: Yes___ No___

Does this student have any diagnosed learning disabilities? Yes_____ No_____
According to your records, has this student violated the Missouri Safe Schools Act? Yes____ No_____

*School Official: There are two copies of this form. Please retain one copy for your file. UB/UBMS staff will collect the other
copy at the scheduled interview day.