Fillable Upward Bound Program Application Section II NOMINATION FORM (Lincoln University)

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Upward Bound Program Application Section II NOMINATION FORM (Lincoln University)

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Lincoln'University'Upward'Bound'Program''
June'2017' Page'1'
Upward Bound Program Application
Section II
NOMINATION FORM
(To be completed by Guidance Counselor)
This form is for the use of schools referring students to the Lincoln University Upward Bound
Program. Please answer all questions and forward completed application to:
Upward Bound Program
Lincoln University
1570 Baltimore Pike
Lincoln University, PA 19352-0999
1. Applicant:____________________________________________________________
Last Name First Name Middle Name
2. High School:__________________________________________Grade:____________
Address:________________________________________________________________
City:___________________________State:________Zip Code + 4:________________
3. Is the applicant a participant in any other TRIO program (ex: Upward Bound Math
Science, Talent Search)?
4. If your position is other than a guidance counselor, please indicate your position and
relationship/general involvement with this student.
5. Is the applicant’s home in an urban or rural area?
6. One of the most important requirements for this program is that each student have
significant potential for academic/personal growth. It is desirable that the student feel
that one of the conditions of his future development is a post-secondary education,
whether or not his/her talents and interests center ultimately in academic pursuits. Any
data which will help us estimate this potential in prospective students is relevant. In
answering the following questions, please feel free to add any such information.
Lincoln'University'Upward'Bound'Program''
June'2017' Page'2'
a) Please list and/or attach all available standardized test scores for the student,
including 8
th
grade PSSA results. Indicate raw scores as well as percentiles (include
I.Q. data, if available). Also indicate the complete name of the test instrument for
which scores are being reported.
_________________________________
_________________________________
_________________________________
___________________________________
___________________________________
___________________________________
b) Please attach a copy of the student’s most recent report card and a transcript for
courses completed. In what areas has the student shown special interest or aptitude?
c) Do you feel that the above information represents a valid reflection of this student’s
abilities?
d) What is the student’s current G.P.A. (if available)?________
Class Rank?________ out of ________
7. Are you in a position to discuss this student’s self-image? _____Yes _____No
If yes, please do so below.
8. What factors in this student’s psychological make-up or environment have helped or
hindered his/her development, academic and otherwise?
9. Please indicate and discuss student’s present grade level in reading. Is the student in need
of remedial help in reading or writing?
10. Discuss student’s potential to perform on the college level.
11. Please indicate the racial composition (%) of your school.
_____African American _____Caucasian _____Native American
_____Asian _____Hispanic _____Other
12. Is this student a member of your school’s ethnic “Majority Group”?
Yes _____ No______
Lincoln'University'Upward'Bound'Program''
June'2017' Page'3'
13. How might you characterize this student’s general school performance?
14. Is this student a participant in any extra-curricular activities at your school?
Yes_____ No_____ If answer is yes, describe activities and list names of school
personnel supervising the specific activities.
15. Additional information for the Upward Bound Staff, such as unusual strengths and
weaknesses, learning disabilities, physical handicaps, etc., should be attached to this form
by way of a summary statement.
16. Do you recommend this student for Upward Bound? (Please check:)
_____ Strongly Recommend
_____ Recommend
_____Recommend with Reservations
_____Do Not Recommend
Additional Comments:_____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Signature:__________________________________________
Name:____________________________________Title:_________________________
(Please Print)
School:________________________________________________________________
Address:_______________________________________________________________
_______________________________________________________________
City State Zip Code + 4
Counselor’s Phone #: Ext. Fax # ________________
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Upward Bound Program Application Section II NOMINATION FORM (Lincoln University)

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Completed 29 January 2021

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