Upward Bound Program Application (School Staff Recommendation Form)

Students - Give this form to a teacher, social worker, coach, principal or assistant principal who knows you well.

Upward Bound is an academic program for high school students who are potentially the first in their family to earn a bachelor's degree or who come from a limited income household. Our program is designed to help students overcome the academic, financial, and personal barriers to get into and succeed in college. We serve a very limited number of students and request your evaluation/recommendation for this student to be considered for the program. If you have any questions, please contact the Program Manager at 217-641-4348 or upwardbound@jwcc.edu.

Student's Name Student's Name First Last
Student's School
(Please complete if known) Parent Name (Please complete if known) Parent Name First Last
Phone Phone - ### - ### ####
Student's Grade

Student's Grade 8th 9th 10th 11th 12th
How long have you known the applicant?
Do you believe the student is currently performing at his/her potential?

Do you believe the student is currently performing at his/her potential? Yes No Somewhat
Do you believe this student has the potential to succeed in college?

Do you believe this student has the potential to succeed in college? Yes Possibly With Reservation No
Why or why not?
What are this student's personal strengths and challenges?
Strengths:
Challenges:
What do you believe are the student's academic, financial, and personal barriers to get into and succeed in college?
Have you had any behavioral or disciplinary problems with this student?

Have you had any behavioral or disciplinary problems with this student? No Yes
If yes, please explain
Why do you believe this student should be accepted into the program?
Student Program Recommendation

Student Program Recommendation Do Not Recommend With Reservation Somewhat Strongly Enthusiastically
Name
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Your Occupation

Your Occupation Teacher Coach Counselor Social Worker Principal/Assistant Principal

Upward Bound Program Application (School Staff Recommendation Form)

Upward Bound Program Application (School Staff Recommendation Form)

What are this student's personal strengths and challenges?