Dear Parent/Guardian:Your child has indicated an interest in the Upward Bound Math & Science-Rural (UBMS-Rural) Program at Texas A&M University-Kingsville. UBMS-Rural is a free college preparatory program for high school 9th and 10th grade students funded by the U.S. Department of Education. UBMS is specifically designed to strengthen the academic skills of eligible high school students to excel academically and pursue postsecondary degrees after high school graduation.

Year-round services provided by UBMS-Rural include:

Tutorial services during the academic school year to strengthen academic skills Workshops and seminars to enhance motivation to succeed in post secondary education A 6 week summer instructional component that is designed to simulate a college-going experience

that includes daily coursework in core curriculum subjects as well as other related activities such as field trips and special events

Academic advising from UBMS-Rural staff and individual assistance with the college admissions and financial aid application process during the academic school year

In order to comply with federal regulations, all UBMS-Rural participants must meet the following criteria:

Indicate an interest in attending college Demonstrate academic need (low grades and/or low test scores) Qualify as Low Income and/or Potential First Generation College Graduate (neither parent

has received a 4-year degree) Commit to remain active in UBMS-Rural until high school graduation

Please complete this application and return it to your child so that he or she may submit it to their counselor. All completed applications will be reviewed and eligible applicants will be contacted within 30 days for a Student and Parent Interview with program staff.

Thank you for your interest in the Upward Bound Math & Science-Rural Program. Please call a UBMS-Rural staff member at (361) 593-4451 if you have any questions or need additional assistance.

Sincerely,

Elvia GarciaProgram Director

PART IC IPANT APPL ICAT ION

S T E P 1 : Please answer the following questions about yourself.

a. What is your name? Last Name

First Name

Middle Initial

b.What is your mailing address?

Street Address Apt. #

City State Zip

c. What is your home phone number?

( ) --

d.What is your cell phone number?

( ) --

e. What is your parents’ name?

Last Name

First Name

f. What is your parents’ cellphone number?

( ) --

Mother Father

g.What is your e-mail address? @

S T E P 2 : Please answer the following questions about yourself.

a. What is the name of your school?

b.What grade are you in? th g r a d e

c. What is your social security number? -- --

d.What is your birthdate? M M / D D / Y Y Y Y

e. Are you Hispanic or Latino? YES NOf. What is your race?

(Please check all boxes that describe you.)

American Indian or Alaska Native

Asian Black or African American

Native Hawaiian or other Pacific Islander

White

g.What is your gender? Female Male S T E P 3 : Please answer the following question about yourself.

a. Are you a U.S. citizen? YES NO, but I am a Permanent Resident. My Permanent Resident Alien Number is:

A

NO; I am not a U.S. citizen, and I am not a permanent resident.

S T E P 4 : Please answer the following questions about your parents and about yourself.

a. Has your mother received/earned a 4-year college degree? YES NO

b. Has your father received/earned a 4-year college degree? YES NOc. Which parent did you regularly reside with and receive support from during

your childhood (i.e., until you were 18 years old)? (Please check only one box.)

Both Mother and Father Neither Mother nor Father

Mother only Father only

PART IC IPANT APPL ICAT ION - CONT INUED

S T E P 5 Your parent(s) must answer the following questions.

a. What is the total number of persons (including you) in your family?

b.What was your family’s taxable (not total) income from the last calendar year?

(Please check only one box. Then, provide the requested income information.)

My family’s taxable (not total) income from the last calendar year was:Note: Taxable income can be found on the federal income tax return. On IRS Form 1040, see line 43. On IRS Form 1040A, see line 27. On IRS Form 1040EZ, see line 6.

$ , .00

My family did not file a federal income tax return for the last calendar year. My family’s total income from the last calendar year was:

$ , .00

My family had no taxable income during the last calendar year. S T E P 6 You (the student) and your parent or legal guardian must read the following statement and then sign and date.

By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of the student’s official academic records to the TRiO program at Texas A&M University-Kingsville, understanding that the information in these records will be used only to assess the student’s need for TRiO program services, discern the student’s educational progress, evaluate the effectiveness of TRiO program activities, and fulfill TRiO program-reporting requirements. Finally, I authorize this TRiO program to use the student’s name, statements and likeness, without charge, for promotional purposes in the project’s publications, advertising, video, and other formats.

Student’s Signature Date

Parent or Legal Guardian’s Signature Date

FOR OFFICEUSE ONLY

The 20___ federal TRIO programs annual low-income level for a family unit with _______ members is:

$ , .00 Recommended Approval Recommended Approval Approved Not Recommended.

Reason: __________________ Not Recommended.

Reason: _______________ Denied

Reason: ___________________

Advisor (Print name)

___/___/20___

Director (Print name)

___/___/20___

P.I. or P.I. Designee (Print Name)

___/___/20___

Advisor (Sign & Date) Director (Sign & Date) P.I. or P.I. Designee (Sign & Date)

Date of Application Entry into Database _____/_____/________ Initials of Data Entry Staff __________ Eligibility: LI&FG LI ONLY FG ONLY HRAF ONLY LI&HRAF FG&HRAF LI&FG&HRAF

Project: UBC UBR UBMS UBMS-R

Revised: RC 11.30.17

AUTOBIOGRAPHY

(This is an important part of the selection process and must be completed; use additional sheets if necessary. Write 3 to 4 sentences per question.)

CHILDHOOD (Birth/Family/Home Life/Early Education)

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

TEEN YEARS (Education/Jobs/Interests/Hobbies/School, Church and Other Activities)

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

FUTURE PLANS (Life Goals, Career Plans, Etc.)

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

OTHER (Include Volunteer Work, Community Service, Other Interests If Not Included Above)

_________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Notice to Parent or Guardian:

Occasionally there is a need for immediate medical attention due to sudden illness or accidents. As you may know, hospitals will not administer medical care unless they have parental consent.

Should an emergency or need for medical or psychological attention or testing occur (clinic, dentist, X-ray), the hospital or clinic must have your consent. Therefore, to assure proper care for you son/daughter, please fill out this form.

______________________________ ___________________Student Signature Date

Statement of Parental Consent

I hereby authorize the Director or designated representative of the program to sign in my place as needed for medical or dental attention.

______________________________ ___________________Parent/Guardian Signature Date

Medical Attention Form

Teacher Recommendation for Student Participation in

Upward Bound Math & Science-RURAL Program at TAMUK

Student: _____________________________________________ School: ____________________________

Teacher: _____________________________________________ School telephone number: ___________________________

Subject: __________________________ Current course grade: __________________

Length of time you have known this student: ________________

Upward Bound Math & Science-Rural is a program designed to generate knowledge, skills, and motivation for success in post-secondary school. Participants should have the ability to succeed in post-secondary school even though they may not now be demonstrating all of the characteristics of successful students. Please rate this student by circling the appropriate response to these statements.

5- Strongly agree 4- Agree 3- Neither agree/disagree 2- Disagree 1- Strongly disagree

1. Expresses interest in academic endeavors 1 2 3 4 52. Demonstrates responsible behavior 1 2 3 4 53. Relates well to peers 1 2 3 4 54. Cooperates with school staff 1 2 3 4 55. Is dependable and reliable 1 2 3 4 56. Would benefit from supplemental academic support and services 1 2 3 4 57. Needs expanded cultural awareness 1 2 3 4 58. Would benefit from supplemental career guidance and information 1 2 3 4 59. Has good attendance, and punctuality, record 1 2 3 4 510. Completes work and assignments in a timely manner 1 2 3 4 511. Will be successful in college endeavors 1 2 3 4 512. Communicates openly with school staff 1 2 3 4 5

Additional comments ________________________________________________________________________________________

___________________________________________________________________________________________________________

_________________________________________________________________________________________________________

This is an important part of the student’s application for Upward Bound Math & Science-Rural. Please return to the counselor as soon

as possible.

______________________________________ ___________________Teacher Signature Date

Teacher Recommendation for Student Participation in

Upward Bound Math & Science-RURAL Program at TAMUK

Student: _____________________________________________ School: ____________________________

Teacher: _____________________________________________ School telephone number: ___________________________

Subject: __________________________ Current course grade: __________________

Length of time you have known this student: ________________

Upward Bound Math & Science-Rural is a program designed to generate knowledge, skills, and motivation for success in post-secondary school. Participants should have the ability to succeed in post-secondary school even though they may not now be demonstrating all of the characteristics of successful students. Please rate this student by circling the appropriate response to these statements.

5- Strongly agree 4- Agree 3- Neither agree/disagree 2- Disagree 1- Strongly disagree

13. Expresses interest in academic endeavors 1 2 3 4 514. Demonstrates responsible behavior 1 2 3 4 515. Relates well to peers 1 2 3 4 516. Cooperates with school staff 1 2 3 4 517. Is dependable and reliable 1 2 3 4 518. Would benefit from supplemental academic support and services 1 2 3 4 519. Needs expanded cultural awareness 1 2 3 4 520. Would benefit from supplemental career guidance and information 1 2 3 4 521. Has good attendance, and punctuality, record 1 2 3 4 522. Completes work and assignments in a timely manner 1 2 3 4 523. Will be successful in college endeavors 1 2 3 4 524. Communicates openly with school staff 1 2 3 4 5

Additional comments ________________________________________________________________________________________

___________________________________________________________________________________________________________

_________________________________________________________________________________________________________

This is an important part of the student’s application for Upward Bound Math & Science-Rural. Please return to the counselor as soon

as possible.

______________________________________ ___________________Teacher Signature Date