The Ohio State ATI

UPWARD BOUND

Program

Yes, I am college-bound and interested in Upward Bound. If I appear eligible, please send me a complete application packet.

NOTE: THIS PROGRAM IS ONLY FOR STUDENTS RESIDING IN THE CANTON, ORRVILLE, and WOOSTER AREAS.

Student's Name:

Student's Street Address:

City    Zip code

Phone:

Student attends, or plans to attend Timken Senior High School McKinley Senior High School Orrville High School Wooster High School

Student's Age:

Student's Grade Average

A B C D F

Current Grade Level: Citizenship Status:

8 9 10 11                      U. S. citizen Other

Student lives with: Both parents Mother Father Grand parent Other

Father's name:

Mother's name:

Guardian's name:

Does the student's mother or father have a Bachelor's degree?    Yes No

Student's Career Goal:

Date:

________________

Signature of Student Date

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