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University Bound Program Student Application #2 John Brewers Bay RR 02 Box 10,000 St. Thomas, VI 00802 Kingshill, VI 00850-9871 (340) 693-1130 (340) 692-4182 Thank you for your interest in the University Bound Program. This application must be completed in full and returned to the University Bound Office. All information are confidential. Applications will be reviewed once all materials are received. If you are selected for an interview, you will be contacted to set up an appointment. Admission into the program is based on financial and academic eligibility, need, readiness for program services and available space. Please Note: Submitting an application does not guarantee admission into the program. Student’s Name: _____________________________________________________ Grade: ______________________________________________________________ School: _____________________________________________________________ Date:_______________________________________________________________ ***NOTE: TO COMPLETE THIS APPLICATION, YOU ARE REQUIRED TO SUBMIT THE FOLLOWING: 1. A copy of your high school transcript and/or your most recent report card 2. A Certified copy (stamped/dated) of your parent’s/guardians last Income Tax Return filed or other document of family income; such as public assistance, social security, retirement, etc. 3. A letter of recommendation as indicated in Part D, from a teacher or counselor 4. An essay, at least 100 words: Write a brief essay defining your career goals. (In what way do you believe U.B. will be able to assist you in achieving those goals? Please attach essay to application. 5. Copies of Standardized test scores Application __Part A 1. Name____________________________________________________________________________________ Last First Middle 2. Physical Address: __________________________________________________________________________ city state zip code 3. Mailing Address: (if different from the physical address) ______________________________________________ P. O. Box # city state zip code 4. Phone No. : ___________________________5. E-mail Address: ____________________________________ 6. Date of Birth: _________ 7. Gender: ____M F 8. Social Security#________________________ 9. Name of High School:_______________________________ 10: Current Grade: ____________________ 11. Place of Birth: ____________________________ (Please show proof of citizenship) 12. Age: _____________ If not born in the U.S. or U.S.V.I., please complete A or B below: _____ A. Naturalized Citizen Date Granted: ___________________________ (please provide copy) _____ B. Permanent Resident Alien Number: ___________________________ (please provide copy) 13. What Language, other than English, is spoken at home? _________________________________________ 14. With whom do you live? Mother ____Father ____Both Parents ____Other: ___________________ 15. How should mail to Parents/Guardian be addressed? (Please check one) ___Mr. & Mrs. ___Mr. ___Mrs. Ms. ___________________________________________ Name 16. How did you hear about the University Bound Program? _______________________________________ 17. List any extra-curricular activities in which you participate. (at school, community, church etc.) ____________________________________________________________________________________________ __________________________________________________________________________________________ 18. What Career Path are you enrolled in high school? (ex: aviation, medical): __________________________ * UVI complies with affirmative action, equal opportunity, Title IX, Section 504 Federal Legislation. PART B. TO BE FILLED OUT BY STUDENT AND SIGNED BY STUDENT AND PARENT/GUARDIAN Please list the people who reside at your home, including yourself and those in college. NAME XXXXXXXXXXXXXX AGE XXXXXXXXXXXXXX RELATIONSHIP XXXXXXXXXXXXXX HIGHEST EDUCATION COMPLETED XXXXXXXXXXXXXXX 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (Use reverse side if necessary) Has either of your parents complete a college degree? Yes _____ No If yes, what degree? _____ Associate _____ Bachelor Masters _____ Ph.D. PLEASE READ: In addition to meeting stipulated eligibility criteria for University Bound participation, selection requirements state that a majority of students served by the program must be potential first generation students. The parent’s signature on this form verifies that the statements regarding the highest grade completed and parent’s college status is accurate as stated here. ___________________________________________ _____________________________________ Parent’s Signature Date What is/are your reason(s) for wanting to join University Bound? _______________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ___________________________________________ ______________________________________ Student’s Signature Date Part C: TO BE FILLED OUT BY PARENT OR GUARDIAN Note: Giving the medical information (questions 1-4 below) is voluntary and not providing it will not affect your child’s acceptance into the program. However, in order to properly plan your child’s educational or remedial program, we request that you provide this information. 1. Please list any medical, psychological, behavioral, or educational problems which may limit your child’s successful participation in Upward Bound. _____________________________________________________________________ _______________________________________________________________________________________________ 2. In case of emergency, what procedure should be followed ________________________________________________ 3. Please list and explain the use of any medication(s) that your child is using. __________________________________ 4. Date of last physical examination:_________________ Medical/Insurance Card#: ___________________________ 5. Please provide household Annual Income information below: Parent (1) Parent (2) Name (parent/guardian) Relationship to Applicant Employer Employer’s Mailing Address Work# / Cell# / Home Job Title Annual Income/before deductions Email Address 6. Do you claim the University Bound applicant as an exemption on your income Tax Return? Y ____N If yes, what status do you use when filing your tax return? ___single ___married, joint head of household. 7. What is the total number of exemptions that you claim on your tax return? _______ Note: Statements made regarding taxable income must be verified. If you do not claim the applicant, please explain the main source of support for this applicant and offer some form of documentation thereof. *University Bound is supported by government funds appropriated to serve students who meet a certain economic criteria. If your child is selected to participate in the program and the information given on this form is false, he/she will be dropped from the program. Parent’s Signature: ___________________________ Date: _______________________________ Part D: RECOMMENDATION TO UNIVERSITY BOUND PROGRAM, UVI ** This form should be completed by a Teacher or Counselor. ** NAME OF STUDENT: ______________________________________________________________ NAME OF HIGH SCHOOL: _________________________________________________________ TEACHER’S OR COUNSELOR’S NAME: _____________________________________________ SUBJECT TAUGHT/TEACHING: ____________________________________________________ DATE: ____________________________________________________________________________ The above student is applying for admission to the University Bound Program. The goal of the program is to provide opportunities to selected eligible high school students with academic potential who are interested in pursuing post-secondary education. The program offers academic instruction, individual and small group tutorials, individual and small group counseling, college admission information, and cultural, social, and recreational activities to its participants. Please help us to complete a need assessment of the above applicant by writing a brief statement below indicating why you think this student should be admitted to University Bound and how we can best serve his/her needs. Please specify academic/social needs, such as improving writing/math skills and exposure to college environment. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Note: Under the Family Educational Rights to Privacy Act of 1974, the candidate is entitled to review this recommendation. Rev.12/2016