South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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APPLICATION
TRIO programs, funded under Title IV of the Higher Education Act of 1965, help
students overcome social, academic and cultural barriers to higher education.
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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The following information describes the Upward Bound (UB) Program, explains what it does, who
qualifies for it, the commitment participants must make, and how the selection process works.
WHAT IS UPWARD BOUND?
UB is a federally funded program, sponsored by the Department of Education. The program
targets, select, and help qualified students that have the desire and potential to succeed in
college and reach their goals.
ALL of the services and activities provided by UB are at NO COST to participants or their
families. The resources used are viewed as an investment in each student’s future. The UB
Program based at South Arkansas Community College (SouthArk) in El Dorado will work with
sixty-three students selected from applicants at El Dorado High School.
WHAT DOES UPWARD BOUND DO?
The UB program assists selected participants in completing secondary school, enrolling in
post-secondary school, and completing a bachelor’s degree by providing intense academic,
career, personal, and financial advising.
It also provides academic instruction in literacy, mathematics, social science, and science, as
well as tutorial services. Additionally, it helps participants obtain college credit courses at
SouthArk after their junior year of high school.
WHO QUALIFIES FOR UPWARD BOUND?
Students selected for the UB program must meet family income guidelines as set forth by the
federal government.
Additionally, neither parent may possess a four-year college degree.
WHAT COMMITMENTS DO UB PARTICIPANTS MAKE? UB participants must make a commitment to the
program.
Meet eighteen (18) Saturdays during the academic year, students meet at SouthArk to work
with academic instructors, prepare for ACT testing, travel to college campuses, and participate
in other exciting social, recreational, and civic activities.
Attend a six-week academic program during the summer on the SouthArk campus. As long as
they meet the requirements of the program, participants remain in Upward Bound until
graduation. UB students receive a participation stipend based on consistent participation.
Meet once monthly for Success Seminar presented by various guest speakers.
HOW ARE PARTICIPANTS SELECTED?
Family income and parental education. We interview qualified applicants and parents. This is
an informal and comfortable process, which takes about half an hour. Afterwards we make final
selections. Please keep in mind that we only accept 63 students.
If you have any additional questions, feel free to call Barbara Howell (870) 864-7100, Roy Williams
(870) 864-8407or Martha Dunn (870) 864-8409 or contact your student’s guidance counselor.
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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Instructions and Information
The Student portion of the application must be completed by the student and the Parent/Guardian portion
must be completed by the parent/guardian. All sections of this application must be completed.
What if I have Questions or need Help? If you have questions or need help, please talk with your
guidance counselor, call Barbara Howell (870) 864-7100, Roy Williams (870) 864-8407or Martha Dunn
(870) 864-8409. To complete your application, please provide only the information requested in the
following Application Checklist. Turn the completed packet in to your guidance counselor.
Application Checklist
The following application checklist provides the sections of the application you and your
parent(s)/guardian(s) must complete.
Return the Student/Parent(s) or Guardian(s) sections of the completed South Arkansas Community
College Upward Bound Application Form to your counselor or to the Upward Bound Student Success
Coach on your campus.
Student/Parent(s) or Guardian(s) Section:
Students and parent(s) or guardian(s) should provide all information in this section, which contains
the following pages:
Student Information
Medical Information
Parent/Guardian Information
Current Year W2 Form or Taxes
Information Release
Essay/Autobiography
Questionnaire
Upward Bound Student Contract
English Teacher
Math Teacher
Science Teacher
Guidance Counselor
This application includes a reference form for your English, Math, Science teachers, and guidance
counselor to complete. You do not have to collect these forms. They will be completed and returned
to the Guidance Office.
After we receive your completed application, we will review it. If you qualify, we will mail you or call
you to set up an interview with you and your parent(s) or guardian(s). Once the interviews are
Please notify Upward Bound staff ASAP if student’s custody/guardianship or residence changes.
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
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completed, we will make final selections. Regardless of whether or not you have been accepted you
will receive a letter welcoming you to the program or explaining to you why you were not selected.
Student Information
Provide the following information as requested. Please print all written responses. Circle or check other answers as appropriate. If you
have questions about completing the application, please contact your guidance counselor or the Student Success Coach on your campus.
Name: ______________________ _____________________ _________________ Social Security No: ______-_____-_______
Last First Middle (Required)
What is your preferred name? ___________________________________________________________________________________
Address: ___________________________________ Phone: (_____) _____ __________ D.O.B. _____/_____/___________
Ci
ty: ___________________________________________________ State: _______________ Zip: __________
El
ementary School: _____________________________________ Middle School: ________________________________________
Junior High School: _____________________________________ High School: __________________________________________
Di
d you repeat a grade? Yes (If yes which grade?) ______ No In what grade are you currently? _____
Gen
der:
Male Female T-Shirt Size Ethnic Origin:
African American/Black
Are you:
a U.S. citizen Asian
an eligible non-citizen (please attach a Caucasian
copy of your immigration documentation)
Hispanic/Latin American
Other ____________________________ Native American
Wha
t is the primary language(s) spoken in your home?
English English/Spanish Other: _______________
Ho
w did you hear about this program?
Guidance Counselor Teacher UB STAFF Other ____________________
What do you plan to do after you graduate high school? (Check all that apply)
Attend a four-year college Attend a community college for a one or two year degree
Enroll in a technical college program Enlist in the military
Get a job Attend a trade school
Other (Please Specify) ___________________________
In what areas can Upward Bound help you? (Use numbers and rank all the following that apply to you in order of
importance with 1 being the most important and 14 being the least important).
Improve my grades Prepare for tests
Build my self-esteem Explore ways to pay for college
Meet new people Learn about college options
Learn about other cultures Study skills
Manage my time
Choose a career
Visit new places
Develop new interests
Visit college campuses ___ Other _____________________
Wha
t courses have you taken or are you currently taking? (Check all that apply)
Algebra I Algebra AB Biology
Algebra II Algebra CD Chemistry
Geometry Integrated Algebra Pre AP or AP classes (List course name)
South Arkansas Community College Upward Bound Program
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Geometry Investigation Physical Science __________________________________
What obstacles or difficulties, if any, do you face that may affect your educational and career plans?
MEDICAL HISTORY & CONSENT FOR TREATMENT & TRAVEL
Student’s Name__________________________________________ Date of Birth____________________________
Address___________________________State____Zip___________Parent/Guardian_____________________________
A.M. Phone #_________________________________ P.M. Phone#_________________________________________
IN CASE OF EMERGENCY, if parent cannot be reached, name of person to notify or to whom we can release student:
Name_________________________________ A.M. Phone#__________________ P.M. Phone#____________________
UNDER NO CIRCUMSTANCES SHOULD STUDENT BE RELEASED TO:________________________________
CIRCLE BELOW ALL OF STUDENT’S PRESENT OR PAST ILLNESSES/CONDITIONS:
Asthma
Eyeglasses
Sleepwalking
Mumps
Convulsions
Contacts
Bed wetting
Frequent sore throat
Tuberculosis
Chicken Pox
Heart trouble
Polio
Diabetes
Measles
Bronchitis
Rheumatic fever
Of the above, these are current or recurring:__________________________________________________________
Please list all current medication? ______________________________________________________________________
ALLERGIES: Bee/wasp stings___ drugs________ foods (specify)_________________ other (specify) _____________
Recently exposed to contagious disease: Yes____ No____ If yes, which?_________________________________
Are you currently receiving therapy? Yes____ No____ If yes, which one:____ physical ____ mental ____rehabilitation
Has student been hospitalized within the past 5 years? Yes____ No____.
Describe physical conditions requiring restrictions for participating in camp programs: ____________________________
__________________________________________________________________________________________________
Is student currently being treated by a physician for an existing illness or condition? Yes______ No_______
If yes, explain
Name of student’s physician or healthcare provider:_______________________________________________________
Address:____________________________________________________________Phone #:_______________________
Is student covered by health insurance? Yes____ No____
Policy type:______________________________ Insurance Company :______________________________
Policy #:________________________________ Exp. Date: ________________________________________
*If the student is covered by TEA, Social Security, or S.S.I., please attach a copy of the medical card to this form.
Family’s physician_______________________________________________________ Phone#:____________________
Parent’s physician_______________________________________________________ Phone#: ____________________
Parent’s Insurance Company_______________________________________________ Member#: __________________
Insurance Company’s address______________________________________________ Phone#:_____________________
Medical Release
I hereby authorize the UPWARD BOUND Program to provide emergency medical and dental services for my child
______________________________________________.
I will not in any way hold South Arkansas Community College or the Upward Bound Program responsible for any treatment
or medication deemed necessary for medical or dental services.
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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Upward Bound participants are not allowed to share his/her medication nor take medication that belongs to other students.
PARENT/GUARDIAN
SIGNATURE_______________________________________________________________________
Print Parent/Guardian name___________________________________________ Date______________________
Parent(s)/Guardian(s) Information
This section must be completed by the parent or guardian with whom the application lives.
**All information provided is confidential**
PARENT INFORMATION
For Family with more than eight members, add the following amount for each additional family member. $6,630
For the 48 contiguous states, the District of Columbia and outlying jurisdictions; $8,295 for Alaska; and $7,620, for Hawaii.
I
certify by signing below that the above information is correct and that any false or misleading information may result in
disqualification of the applicant
.
Parent/Guardian Signature _______________________________________________________ Date: _____/_____/________
Parent/Guardian Signature _______________________________________________________ Date: _____/_____/________
(Effective January 15, 2020 until further notice)
Size of Family Unit
48 Contiguous States, D.C., and Outlying
Jurisdictions
Alaska
Hawaii
1
$19,140
$23,925
$22,020
2
$25,860
$32,325
$29,745
3
$32,580
$40,725
$37,470
4
$39,300
$49,125
$45,195
5
$46,020
$57,525
$52,920
6
$52,740
$65,925
$60,645
7
$59,460
$74,325
$68,370
8
$66,180
$82,725
$76,095
1. I
f you are employed and filed an income tax return, please indicate yearly wages $____________
(a copy of your most recent Income Tax Return is required; W-2 forms are not accepted
2. If you ae no employed and did not file a tax return, please complete the following for the most recent year:
Social Security/SSI$_________________________ Pension/Retirement_______________________
TEA $ ____________________________________ VA/GI Bills______________________________
Unemployment_____________________________ Food Stamps $___________________________
Other (specify) $__________________________________________________________________________
TRAVEL CONSENT: I hereby give my consent to the Upward Bound Program to take my son/daughter on outings
sponsored by the program. Signature of Parent/Guardian:_______________________________________Date: ___________
Name____________________________Relationship _________________________Contact Number_______________
O
ccupation________________________Employer___________________________Employer Number______________
Name____________________________Relationship _________________________Contact Number_______________
Occupation_______________________ Employer___________________________Employer Number______________
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Num
ber of family members in household: Adults__________ Children___________
Is either parent a graduate of a four-year college or university with a Bachelor’s Degree? Yes__No__
Information Release
Please print your first name, middle initial, and last name where indicated in the following release statement.
Afterwards, both student and parent(s) or guardian(s) must sign and date this request.
I (First Name) _____________________ (Middle Initial) ____ (Last Name) _____________________________
authorize South Arkansas Community College Upward Bound Program and El Dorado High School to release
and/or receive copies of my son’s/daughter’s/ward’s academic records, including, but not limited to transcripts,
grade reports, test scores, evaluations, attendance and medical records, disciplinary actions, and other records
necessary to for participation in the program. This information may be used for any federal reports of the Upward
Bound program. These records will remain confidential and will only be used by the Upward Bound staff. This
release is to be effective throughout my high school and college career, and will end upon college graduation or
termination from the Upward Bound program.
Student Signature___________________________________________________ Date: _____/_____/________
Parent/Guardian Signature ___________________________________________ Date: _____/_____/________
Parent/Guardian Signature ___________________________________________ Date: _____/_____/________
Parental Release for Student Travel and Photo Release
I authorize the Upward Bound Program to provide transportation for my child___________________________ to program
activities. I hereby release the Upward Bound Program and South Arkansas Community College from any responsibility
for any criminal act of malice, vandalism, theft, or any other unlawful behavior during trips sponsored by the Upward Bound
Program.
The S
outh Arkansas Community College Upward Bound has my permission to use my or my child’s photograph
publically to promote the South Arkansas Community College Upward Bound. I understand that the images may be used
in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee
or other compensation shall become payable to me by reason of such use.
Parent/Guardian Signature____________________________________________ Date_________________________
South Arkansas Community College Upward Bound Program
A FEDERALLY FUNDED PROGRAM
TRIO programs, funded under TITLE IV of the Higher
Education Act of 1965, helps students overcome social, academic and cultural
barriers to higher education.
FormSouthArkUB_App_2019
Revised 03/12/2020
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Essay/Autobiography
Please write a short autobiographical essay of your life history. The information you include here is confidential and is essential in
consideration for selection in the Upward Bound Program. If you require additional space you may write on the back of this page or
attach an additional sheet of paper. Be concise and include the following information.
Family, people or events that have had a significant impact on your life
Personal goals, hopes and dreams
Career interests
Why you want to be a part of the Upward Bound Program
South Arkansas Community College Upward Bound Program
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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School Activities, hobbies, likes, dislikes and anything else that will help us to get to know you better
South Arkansas Community College Upward Bound Program
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Why?
2. ___________________________________________________________________________________
Why?
3. ___________________________________________________________________________________
Why?
4. ___________________________________________________________________________________
Why?
Questionnaire
Name four friends whom you most admire and why.
1. ___________________________________________________________________________________
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
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Identify two places in Arkansas you would like to visit.
1. ____________________________________________________________________________________
2. ___________________________________________________________________________________
Identify two places in the United States you would like to visit.
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
Identify two places in other countries you would like to visit.
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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UPWARD BOUND STUDENT CONTRACT
I agree to achieve and maintain a 2.5 Grade Point Average
I a
gree to contact Upward Bound if there is a change in my class schedule,
my home address or phone number, and/or if my family plans to move from
the target area.
I
agree to seek help with academic or personal problems if needed.
I
agree to attend school regularly and not miss more than 8 days of scho
ol
p
er semester.
I
agree to participate in tutoring sessions as needed and/or recommended by
my counselor or teacher.
I agree to achieve my goals that have been set up with the help of UPWARD
BOUND.
I agree to take advantage of special UPWARD BOUND activities, like the
Saturday Academy, Summer Scholars Academy, UB Success Seminars,
career fairs, college visits, financial aid workshops, and other activities the
staff implement.
I agree to enroll in a postsecondary educational institution upon graduation
from high school.
Student Signature______________________________________ Date______________________
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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English Teacher Reference
Student Name _______________________________________________________________________________________________
School
________________________________________________ Grade ________ Course _________________________________
Teacher Name _______________________________________________________________________________________________
Teacher: The applicant above has applied to the SouthArk Upward Bound Program. Please answer the following questions and evaluate
this student as objectively as possible. All information is confidential. If you have questions, please call Barbara Howell (870) 864-
7100, Roy Williams (870) 864-8407or Martha Dunn (870) 864-8409. Thank you for your assistance.
Important: After completion, please return this form to the school guidance counselor as soon as possible. Do not return to the
student.
Yes No
1. Do you feel that this student had/has an adequate background for this class?
2. Did/Does this student ask for additional help?
3. Did/Does this student take adequate notes?
4. Did/Does this student have a positive attitude in this class?
5. Did/Does this student complete and turn in homework assignments consistently?
6. Do you feel that this student knows how to study?
7. Did/Does this student demonstrate punctuality?
8. Did/Does this student cooperate with school officials?
9. Has this student expressed an interest in post-secondary education?
10. Do you feel that this student has acceptable social skills?
11. Do you feel that this student has a need for more cultural awareness?
12. To the best of your knowledge, does this student have any illegal habits?
(for example, underage tobacco use, alcohol, drugs, etc.)
13. Do you feel that this student has the potential to succeed in college?
14. Do you feel that this student interacts well with his/her peers?
15. What services would you recommend for this student to prepare him/her for high school and/or college?
16. How would you rank this student on a 1- 10 scale, with 10 being the highest? _________
(Please make comments as needed. If you require additional space you may write on the back of this page)
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
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T
eacher Signature ______________________________________________________________ Date: _____/_____/________
Math Teacher Reference
Student Name _______________________________________________________________________________________________
Sc
hool
________________________________________________ Grade ________ Course _________________________________
T
eacher Name _______________________________________________________________________________________________
T
eacher: The applicant above has applied to the SouthArk Upward Bound Program. Please answer the following questions and evaluate
this student as objectively as possible. All information is confidential. If you have questions, please call Barbara Howell (870) 864-
7100, Roy Williams (870) 864-8407or Martha Dunn (870) 864-8409. Thank you for your assistance.
Important: After completion, please return this form to the school guidance counselor as soon as possible. Do not return to the
student.
Yes No
1. Do you feel that this student had/has an adequate background for this class?
2. Did/Does this student ask for additional help?
3. Did/Does this student take adequate notes?
4. Did/Does this student have a positive attitude in this class?
5. Did/Does this student complete and turn in homework assignments consistently?
6. Do you feel that this student knows how to study?
7. Did/Does this student demonstrate punctuality?
8. Did/Does this student cooperate with school officials?
9. Has this student expressed an interest in post-secondary education?
10. Do you feel that this student has acceptable social skills?
11. Do you feel that this student has a need for more cultural awareness?
12. To the best of your knowledge, does this student have any illegal habits?
(for example, underage tobacco use, alcohol, drugs, etc.)
13. Do you feel that this student has the potential to succeed in college?
14. Do you feel that this student interacts well with his/her peers?
15. What services would you recommend for this student to prepare him/her for high school and/or college?
16. How would you rank this student on a 1- 10 scale, with 10 being the highest? __________
(Please make comments as needed. If you require additional space you may write on the back of this page)
T
eacher Signature ______________________________________________________________ Date: _____/_____/________
South Arkansas Community College Upward Bound Program
FormSouthArkUB_App_2019
Revised 03/12/2020
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Science Teacher Reference
Student Name _______________________________________________________________________________________________
Sc
hool
________________________________________________ Grade ________ Course _________________________________
T
eacher Name _______________________________________________________________________________________________
T
eacher: The applicant above has applied to the SouthArk Upward Bound Program. Please answer the following questions and evaluate
this student as objectively as possible. All information is confidential. If you have questions, please call Barbara Howell (870) 864-
7100, Roy Williams (870) 864-8407or Martha Dunn (870) 864-8409. Thank you for your assistance.
Important: After completion, please return this form to the school guidance counselor as soon as possible. Do not return to the
student.
Yes No
1. Do you feel that this student had/has an adequate background for this class?
2. Did/Does this student ask for additional help?
3. Did/Does this student take adequate notes?
4. Did/Does this student have a positive attitude in this class?
5. Did/Does this student complete and turn in homework assignments consistently?
6. Do you feel that this student knows how to study?
7. Did/Does this student demonstrate punctuality?
8. Did/Does this student cooperate with school officials?
9. Has this student expressed an interest in post-secondary education?
10. Do you feel that this student has acceptable social skills?
11. Do you feel that this student has a need for more cultural awareness?
12. To the best of your knowledge, does this student have any illegal habits?
(for example, underage tobacco use, alcohol, drugs, etc.)
13. Do you feel that this student has the potential to succeed in college?
14. Do you feel that this student interacts well with his/her peers?
15. What services would you recommend for this student to prepare him/her for high school and/or college?
16. How would you rank this student on a 1- 10 scale, with 10 being the highest? )
(Please make comments as needed. If you require additional space you may write on the back of this page)
Teacher Signature ______________________________________________________________ Date: _____/_____/________
South Arkansas Community College Upward Bound Program
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Guidance Counselor
STUDENT RATING SCALE
(To be completed by Counselor)
Student’s Name__________________________________ Grade______ School _________________________
I. ACADEMIC DATA
Current GPA_________ Cumulative GPA_________ Total Number of units_________
II. TEST DATA:
Please provide copies of: ACT ASPIRE and any other current test data that would assist the Upward Bound staff in developing
an appropriate individual instruction plan.
III. COUNSELOR OBSERVATIONS:
Keeping in mind the Upward Bound goal, which is to generate the skills and motivations essential to achieving success in
postsecondary education, please respond to the following:
A. Please assess this student’s ability to follow rules and regulations (please identify significant disciplinary problems
encountered)
B. Would you classify this student as:
At risk ____Yes ____No If yes, please explain
Gifted and talented ____Yes ____No Please identify areas
Learning Disabled ____Yes ____No If yes, please define disability/disabilities and indicate the extent
In what way can Upward Bound best address this student needs?
Relate this student’s potential for success in secondary education
___________________________________________ _______ _____________________
Counselor’s Signature Date
NOTE: PLEASE ATTACH A COPY OF CURRENT TRANSCRIPT.
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