2010 Upward Bound Application[1]

UPWARD BOUND
2010
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.

The Upward Bound program at RMCC is funded in total (100%) by federal grant funding from the U.S. Department of Education, with an
annual budget of $339,381. For questions and other information, please contact Brenda Miner, Director of TRIO Secondary Programs at
479-243-0739, extension 1642.

Dear Parent:

Thank you for considering Upward Bound for your student! Let us take a moment to fill you in on our program,
the process involved in your student’s acceptance, and the commitment required of you and your student.

Upward Bound is a federally funded program, sponsored by the Department of Education. The Upward Bound
program based at Rich Mountain Community College in Mena works with approximately sixty-five 9-12 grade
students in the high schools from Polk, Montgomery, and Scott counties. We are a unique and elite group.

The Upward Bound program at Rich Mountain Community College assists selected participants in grades 9
through 12 to complete secondary school, enroll in post-secondary school, and complete a bachelor’s degree by
providing intense academic, career, personal, and financial advising; academic instruction in language arts,
mathematics, foreign language and science; tutorial services; college credit courses after their junior year of high
school at Rich Mountain Community College; college credit courses after their high school graduation at Rich
Mountain Community College; and cultural and recreational activities throughout the year to increase program,
staff, and participant bonding. The UB program provides professional development opportunities/activities to
strengthen/supplement the professional skills of the staff.

Who are we looking for? Upward Bound participants must meet family income guidelines as set forth by the
federal government. Additionally, neither parent may possess a four-year college degree. Our focus is to target,
select, and help those students in our area that have the desire and potential to succeed in college actually reach
their goals. These students do not have to be the top students in their class, merely solid students with a certain
academic, social and/or cultural need. If selected for this program, your student will be provided with all the
services listed on the adjoining pages, and upon entrance into college, should have completed about of 12 college
hours that will transfer to any college in Arkansas.

“UBers” do have to make quite a commitment to the program. They meet at least one hour a week after school
with an academic tutor, receiving academic support; another day with their designated UB Coordinator, receiving
support and enrichment in a variety of activities; and two Saturdays a month, where we include ACT preparation
classes, campus tours, etc. During the summer, all UBers are required to attend a six-week academic component,
which is highly rewarding. As long as they meet the requirements of the program, they remain in Upward Bound
until graduation.

The selection process is relatively painless. After we collect all applications, we will screen the applications for
those qualified based upon family income and parental education guidelines. Therefore, we will have to ask you
for some financial information. It will be kept completely confidential. Generally, if the applicant qualifies, they
are granted an interview that takes place at a nearby high school. This is informal. (They don’t need to feel
nervous.) We will interview the applicant and parent. The whole process takes about thirty minutes. After we
have completed the interview process, we will make the final selections. Those selected will start at the end of
October or early November. Please keep in mind that we are only able to take in about 15 students per year from
all nine schools, so if your student is not selected, it is not necessarily a reflection on their intelligence or abilities.
They are also welcome to reapply next year.

We hope that this letter answers a few of the questions that parents often ask. If you have any additional
questions, feel free to call (479) 394-7622, ext. 1633 or ext. 1632.

Sincerely,
Rodney Rowland & Jimmy Rackley

479-243-0739, extension 1642.

Instructions and Information

The Student Information section of the application must be completed by the applicant, and the Parent/Guardian section must
be completed by the applicant’s parent/guardian(s).

If you have questions, please talk to your counselor or call the Upward Bound office at (479) 394-7622,
Rodney Rowland (ext. 1633), or Jimmy Rackley (ext. 1632). To complete your application, please
follow the checklist below and turn the packet in to your counselor or mail to:

Rich Mountain Community College
Upward Bound
1100 College Drive
Mena, AR 71953

The application deadline for 2010 is September 30.

Application Checklist
Return the items mentioned below in bold type to your high school counselor or to the UB office.

(1) Application
o Applicant completes Student Information section of application (the teacher reference blanks
must all be complete)
o Parents/Guardians complete Parent/Guardian section of application
o Student and parent sign the release form
o Student completes the essay/autobiography page (can be typed on another sheet or handwritten)
o Give your math and science teachers and counselor the referral forms. Instruct them to return the
completed forms to the counselor. We will pick up the recommendations from your counselor.
Do not send them with your application!

(2) Transcript
o Obtain an official transcript with test scores from your counselor.
What’s Next?
1. After your application is submitted, we will review your application with all the others.
2. If you qualify, we will mail you or call you to set up an interview with you and your parent(s).
3. After we have completed all interviews, we will make the final selections.
4. You will receive a letter from us whether or not you have been accepted.
5. If you are accepted- great! Welcome to UB! If not, we will send you a letter explaining why you were not accepted.

479-243-0739, extension 1642.

Student Information
(Please Print)

Name: _______________________________________ Social Security No: ______-_____-_______
Last First Middle (Required)
Name Preferred: _____________________ Email: ____________________ D.O.B ___/___/_____

Address: ____________________________ Phone: ( ) -______ Cell: ______________

City: ________________________ State: ___ Zip: _______ High School: ______________________

Grade: 9 10 11 Gender: ___ Male ___Female Ethnic Origin:
___ African American/Black
Are you: ___ a U.S. citizen ___ Asian
___ an eligible non-citizen (please provide a ___ Caucasian
copy of immigration documentation) ___ Hispanic/Latin American
___ Other ___ Native American
___ Other: ____________________

What is the primary language(s) spoken in your home? ___ English ___ English/Spanish
___ English ___Other: _______________

How did you hear about this program? ___ Counselor ___ Teacher ___ UB Student ___ 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? (check all that apply and rank them in order of importance)
___ Manage my time ___ Improve my grades ___ Prepare for tests
___ Choose a career ___ Build my self-esteem ___ Explore ways to pay for college
___ Visit new places ___ Meet new people ___ Learn about college options
___ Develop new interests ___ Learn about other cultures ___ Study skills
___ Visit college campuses ___ Other _____________________

Please check the courses that you have taken or are currently taken.
___ Algebra I ___ Algebra AB ___ Biology
___ Algebra II ___ Algebra CD ___ Chemistry
___ Geometry ___ Integrated Algebra ___ Other Math or Science (describe)
___ Geometry Investigation ___ Physical Science _____________________________

What obstacles or difficulties do you face that may affect your educational and career plans?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
479-243-0739, extension 1642.

Please indicate who will submit the recommendation forms for you and which school they are located.

___________________________________________________________________________________
Name of 09-10 English Teacher School

____________________________________________________________________________________
Name of 09-10 Math Teacher School

____________________________________________________________________________________
Name of 09-10 Science Teacher School

____________________________________________________________________________________
Name of Counselor or other Personal Reference School

Parent/Guardian Information
This section must be completed by the student’s parent/guardian(s). If you have questions, please call the UB office at
(479) 243-0739 ext. 1632 or 1633.
Confidentiality of Information
No one is allowed to see the information you provide unless he/she is an employee of Rich Mountain Community College
TRIO programs or otherwise authorized to see this information. All information provided in this section is protected by the
Privacy Act and is not specifically reported to the federal government or the U.S. Department of Education. However, the
Department of Education does have the authority to gather general statistical data about program participants in order to
improve and measure the success of the Upward Bound program.
Father/Male Guardian Mother/Female Guardian

______________________________________ ______________________________________
Last First MI Last First MI

Highest education level completed: Highest education level completed:
___ Elementary School (K-8) ___ Elementary School (K-8)
___ High School (9-12) ___ High School (9-12)
___ Associate’s Degree ___ Associate’s Degree
___ Bachelor’s Degree or beyond ___ Bachelor’s Degree or beyond

Marital Status: ___ Married ___ Divorced ___ Separated ___Unmarried ___ Widowed ___ Other
Student primarily lives with _____________________________
Parent/Guardian Name

Please complete all blanks. If parents are separated, this should be completed by the parent whom the
student lives with, or by the parent/guardian providing at least 50% of student’s financial support.
Parents’ Occupation: Father: _____________________ Mother: ____________________________
Father’s Work Phone Number: ____________________ Mother’s Work Number: _______________
Parent(s)’ taxable income (see line 43 of 2009 Form 1040, line 27 of 2009 1040A or line 6 of 2009
1040EZ)_________________ If income was $0, please explain. _______________________________
Number of people in household: Adults _____ Children _____

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(s)’ Signature

479-243-0739, extension 1642.

Information Release Form

RICH MOUNTAIN COMMUNITY COLLEGE
UPWARD BOUND PROGRAM

Permission to Release Information

for _________________________________

Student’s Name (Please Print)

I authorize Rich Mountain Community College Upward Bound Program and ______________________
High School to release and/or receive copies of my son’s/daughter’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. Otherwise, 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 be terminated only upon college graduation or termination
from the Upward Bound program.

__________________________________ Date: __________________
Student Signature

__________________________________ Date: __________________
Parent/Guardian Signature

Disclosure of Information. The Program may disclose and/or publicize both the Upward Bound
participant's and the parents' identities in connection with academic, promotional or fund raising
activities for the program. The parent and the Upward Bound participant, after becoming an
undergraduate student at an institution, grant the Upward Bound program permission to reveal
his/her academic records in connection with keeping statistical data on the program or in fund
raising for or publicizing the program; such use of the Upward Bound participant’s
undergraduate academic records shall be limited to circumstances in which the Upward Bound
participant's name is not linked with his/her individual grades unless, however, permission is
otherwise obtained.

_________________________________ Date: __________________
Student Signature

_____________________________________________ Date: __________________
Parent/Guardian Signature

479-243-0739, extension 1642.

PLEASE NOTE: Completion of this essay is instrumental to the Upward Bound selection process.

AUTOBIOGRAPHY
(Confidential)

On this page, please write an essay of your life history. Be sure to include information-
1. about your family, people or events that have had a significant impact on your
life.
2. on your personal, goals, hopes and dreams.
3. about your career interests
4. on why you want to be a part of the Upward Bound Program
Include hobbies, likes, dislikes, and any other information that will help us to get to
know you better. Please feel free to write on the back or on an additional piece of paper.

All information will be held in the strictest confidence. When finished, please submit
this with your completed application.

479-243-0739, extension 1642.

RICH MOUNTAIN COMMUNITY COLLEGE UPWARD BOUND
ENGLISH TEACHER REFERENCE FORM

STUDENT___________________________________________DATE ____________________

SCHOOL______________________________________GRADE/COURSE ________________

TEACHER’S NAME ____________________________________________________________
Teacher: The applicant above has applied to the RMCC Upward Bound program. Please evaluate this student as
objectively as possible. All information will be held in the strictest confidence. After completion, please return this form
to the school counselor as soon as possible. Do not return to the student. If you have questions, please call Rodney
Rowland at (479) 243-0739 ext. 1633 or Jimmy Rackley ext. 1632. Thank you for your assistance!

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
(underage tobacco use, alcohol, drugs, et.)?

___ ___ 13. Do you feel that this student has the potential to succeed in college?

14. What services would you recommend for this student to prepare him/her for high school and/or
college?________________________________________________________________________

15. How would you rank this student? Circle the ranking. Superior=4 pts, Average=2 pts, Poor=0 pts.
Please comment._________________________________________________________________

_________________________________________________________________________________
479-243-0739, extension 1642.

Rich Mountain Community College- Upward Bound
Math Teacher Reference Form
STUDENT:__________________________________________DATE ______________

SCHOOL_______________________________GRADE/COURSE ________________

TEACHER’S NAME _____________________________________________________

YES NO











___ ___ 12. To the best of your knowledge, does this student have any illegal habits


college?_______________________________________________________________________

Please comment. ______________________________________________________________________

_____________________________________________________________________________________
479-243-0739, extension 1642.

RICH MOUNTAIN COMMUNITY COLLEGE UPWARD BOUND
SCIENCE TEACHER REFERENCE FORM

STUDENT___________________________________________DATE ______________

SCHOOL________________________________GRADE/COURSE ________________

TEACHER’S NAME ______________________________________________________

YES NO











___ ___ 12. To the best of your knowledge, does this student have any illegal habits?

college?_______________________________________________________________________

Please comment. ______________________________________________________________________

_____________________________________________________________________________________
479-243-0739, extension 1642.

Upward Bound
Counselor Referral Form

Note: Please attach a current transcript and a copy of current Benchmarks, End of Course,
Stanford and/or ACT testing reports.

Student Date

School Grade

Counselor’s Name

I highly recommend this person for the Upward Bound Program (Superior)
I recommend this person for the Upward Bound Program (Average)
I do not recommend this person for the Upward Bound Program (Poor)

Comments: (please reply as honestly as possible)

Signature Date

479-243-0739, extension 1642.

2010 Upward Bound Application[1]

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