Upward Bound Reference / Nomination Form

(For best results, please fill out this form using the Google Chrome Browser.)

Student Being Nominated *

Reference/Counselor/Teacher's Name *

Mailing Address *

City *

State *

Zip *

Phone *

Email *

Who are you to the student being nominated? * Science Instructor Mathematics Instructor Guidance Counselor Other

If "Other," Please List

Why do you feel this student would benefit from the NWOSU Upward Bound Programs? *

Based on your knowledge of the applicant, please list below how you rate the student’s characteristics and academic skills. Below Average – 1; Average – 2; Above Average – 3; Outstanding – 4; No Observation – N/O

Academic Achievement *

Math Skills *

Reading Skills *

Science Skills *

Study Skills *

Writing Skills *

Use of Time *

Responsibility *

Tolerance of Minor Disappointments *

Potential for Growth *

Oratory Skills *

Enthusiasm *

Honesty/Integrity *

Organizational Skills *

Attendance *

Self-motivation *

Peer Relations *

Respect for Authority *

Leadership Potential *

Creativity *

Extracurricular Involvement *

Concern for Others *

Self-Esteem *

Concern for Self *

Sense of Humor *

Self-Discipline *

In what other capacity have you known the applicant? *

How long have you known the applicant? *

My Recommendation for Admission to Upward Bound Program * I Do Recommend I Do Not Recommend

Today's date *

Terms & Conditions

By checking this box, I'm providing my electronic signature.