what is upward bound math science? - northwest … · upward bound math & science application -...

Upward Bound Math & Science Application -

(660) 562-1538 or 562-1632 www.nwmissouri.edu/trio/ubms

What is Upward Bound Math Science?

Upward Bound Math Science is a federally funded program for high school students from low-income

backgrounds and/or potentially the first generation in their family to complete a 4-year college degree. The

primary objective of the program is to assist students in preparing for a post-secondary education in the fields

of math and science.

(Check for eligibility: www.nwmissouri.edu/trio/ubms/eligibility.htm)

In addition to school year services, the primary portion of the program

consists of a six-week residential summer program. During this

portion, the students live in University housing and participate in a

wide variety of activities, including both academic and

recreational/social activities. The academic schedule includes classes

taught by high school and college instructors in the standard core areas

of math, science, literature, composition and foreign language

exposure. All courses are geared towards college preparation. Classes

are very small and each student receives a great deal of individual

attention. The program provides a positive learning atmosphere and

personal interaction between teachers and students. Upward Bound Math

& Science students have full access to University facilities. The entire

range of student participation is shared and supervised by tutor/mentors,

college students who work for the program and live in the residence hall

with the students.

Application Process:

The application form must be completely filled out by you and

your parents/guardians.

We must have your social security number. If you do not have one, you should apply for it

immediately.

A signed copy of your parents’/guardians’ most recent federal income tax return, showing taxable

income. We only need the first 2 pages. If you did not file, we need proof of income (SSI).

The recommendation forms must be completed by math and science teachers and school counselor (or

other person in a similar position). These forms must be placed in an envelope and sealed.

A copy of your transcript, up to and including the last semester/trimester grades, is required. Recent

midterm grades would also be helpful.

A copy of your 8th Grade State Assessment scores in reading and math.

How can UBMS help you?

Advising: Academic Advising

Class Scheduling

Postsecondary Education Selection

Choosing College Majors & Careers

College Application Assistance

Academic Support:

Academic Year Services

Mentoring Program

ACT Prep

Career Exploration:

Field Trips Exploring Math &

Science Careers

Guest Speakers

Financial Assistance:

FAFSA Information and Assistance

Financial Literacy Workshops

Scholarship Assistance

Mandatory Summer Program:

6-week Residential Program

Math & Science Courses Taught by

High School and College Instructors



About Me: *1. First Name MI Last Name

I prefer to be called (name):

*2. Social Security # - - *3. Sex: Male Female

*4. Current Age: *5. Date of Birth: (month) (day) (year)

*6. Check ONE to complete the sentence: I am

a U.S. citizen. a Permanent Resident. (PR # ). applying for citizenship.

*7. Ethnicity/Race Background: (For reporting purposes only. NOT used for selection.) If appropriate, mark more than one.

7A. Are you Hispanic/Latino/Latina? Yes No

7B. Check all of the following that apply to you:

American Indian/Alaskan Native. Asian What heritage?

Black or African American White/Caucasian

Native Hawaiian/Pacific Islander

*8. Parent(s) Mailing Address: *9. Phone #sc/o (Mr. Ms. Mr. & Mrs.) My Home Phone: ( )

Cell Phone: ( )

Street Address: Parent’s

Cell Phone: ( )

City, State, ZIP Work Phone: ( )

*10. My email address:

Parent(s) email address:

About My School and Future Plans:

*11. Current Grade: 9 10 11 Expected year of graduation: Estimated Cum. GPA __________ (on a 4.0 scale)

*12. High School Name:

*13. Counselor’s Name: Counselor’s email:

*14. List the Math, Science and Computer courses (a) you have taken, (b) you are currently taking, and (c) you plan to take.

Grade in

school

Math

classes

Science

classes

Computer related

classes

9th

10th

11th

12th

*15. Please list at least three (3) careers that you are interested in or are considering.

1st choice 2nd choice 3rd choice

Student Demographic Information



Student Name _________________________________________________________

UBMS is required to verify that our participants meet federal criteria based on educational background and household income level. All information provided is kept completely confidential.

Does the student live with the natural/adoptive mother? Does the student live with the natural/adoptive father?

Yes No Yes No

There is no female parent in the household. There is no male parent in the household.

Are you a ward of the court? Yes No If yes, please give the name and phone number of your legal guardian.

(Name) ________________________________________________ (Phone) ______________________________

Household Income Information (required by U.S. Department of Education)

Taxable Income from most recent taxes (income after all deductions) (Refer to IRS Form 1040 line 43, or IRS Form 1040 A line 27, or IRS Form 1040 EZ line 6)

$_____________________________________________ OR

I did not file a tax return – Please list your parental monthly take home pay (including child support, social security, etc.)

$_________________________________________ If applicable, state case #: _______________________

List the names (including the student applying), relationship to the student, and ages of each person that lives in your household:

Name Relationship Age

1. ME

2.

3.

4.

5.

6.

7.

8.

The student’s natural/adoptive mother’s highest level of education (check only one blank):

___ Some high school ___ High school degree ___ Some college ___ Associate’s degree (2 year) ___ Bachelor’s degree (4 year) ___ Master’s or Doctorate degree

The student’s natural/adoptive father’s highest level of education (check only one blank):

___ Some high school ___ High school degree ___ Some college ___ Associate’s degree (2 year) ___ Bachelor’s degree (4 year)

___ Master’s or Doctorate degree

I certify that all of the above information is true and complete to the best of my knowledge.

___________________________________________________ _________________________ Parent/Guardian Signature Date



Please type or write legibly approximately 100 words in response to each of the following questions. These essays

should be your ideas. (You may respond to these items using a computer and print out the responses on a different sheet. Sign it at the bottom.)

*1. How would your personal strengths (those qualities or traits you have confidence in or trust about yourself)

contribute to our UBMS community?

*2. Former UBMS participants have stated that they have overcome many of their personal limitations during

the 6-week UBMS enrichment program experience. How will living and learning with a diverse group of high

school students having similar interests in math and science help you overcome your limitations?

*3. What academic need(s) do you have that UBMS could help you meet?

Improve my study skills Improve my communication skills

Improve my attitude about school Improve my school attendance

Improve my grades Participate more in class

Improve my math skills Improve my science skills

Other______________________________________________________________________________

*4. Are you currently enrolled in any of the following TRIO programs?

Upward Bound Talent Search Gear-Up I am not a participant in any other TRIO program.

*Please sign here to indicate that this is your own work.

(Signed) (Date)

Student Essays



The US Education Department requires that all applicants read this Statement of Confidentiality:

"The personal information you give to the Director of Upward Bound Math & Science may be sent to the Department of

Education. The Privacy Act protects the information. No one may see the information unless he or she works with or for

the Upward Bound Math & Science Program, or is specifically authorized to see the information. The information is

necessary to determine if the applicant is eligible to participate in the program and helps the federal government to

measure your success. The Department of Education has the authority to gather information to help make Upward Bound

Math & Science a better program (20 USC 1231a). If you do not give this information to the Upward Bound Math &

Science Program and the Department of Education, you cannot receive any benefits from the program."

Understandings:

Understand that the completion of this application does not guarantee acceptance in the UBMS program.

Understand that if the student is accepted and wishes to attend UBMS, he or she will be required to be in

attendance the entire summer program period (six weeks) including the weekends.

Understand that the student's family/guardian must assume responsibility for providing medical release forms

upon the student's acceptance to the program.

Understand that the student and parent(s) may participate in answering questionnaires and other appropriate and

approved research projects done as a part of the program's evaluation.

Understand that round-trip mileage will be paid (1) for the Spring Orientation, (2) for delivering the student at

the start of the summer program, (3) for the Weekend Home, and (4) for returning the student home at the end of

the summer program.

Understand that should the student withdraw/leave before the end of the program, parents will assume the travel

expenses.

Understand that stipends, room, board, accident insurance, and laboratory fees are provided free of charge to

the participants.

Authorize the release of my high school and college records (transcripts, standardized tests scores, special needs

documentation, high school and college enrollment status, financial information) to UBMS.

Authorize the release and exchange of the student financial aid information from college and federal

government to UBMS.

Authorize the use of my photograph in publications, Facebook, and media releases for the UBMS program.

Authorize UBMS staff to transport my (our) student to and from UBMS activities.

CERTIFICATION and AGREEMENT:

I (We) hereby certify (1) that I/we have read the Statement of Confidentiality and (2) that the information

provided or amended in this application is true and correct to the best of my (our) knowledge.

Program goals are to work with eligible participants to graduate from high school and enroll in post-secondary

programs of study. I am aware that I (the parent/guardian) have a responsibility to support and encourage my

son/daughter to successfully complete the goals of the program.

Statement of Confidentiality and Understandings

Printed Name of Student Signature

Date

Printed Name of Parent/Guardian Signature

Date

Date

Date


To the Applicant

BEFORE YOU SEAL AND MAIL THIS APPLICATION

(Do NOT mail this page.)

For Your Application To Be Complete, we need...

... from you: • student demographic information pages 1 and 2 • essays with signature on page 3 (or separate sheet) • signature on page 4

... from your parent(s): • information on page 2 • signature on page 2 and 4 • copy of first 2 pages of your most recent federal income tax form (signed)

showing taxable income, OR proof of non-taxable income (SSI)

... from the school: (May be mailed separately.) • an up-to-date transcript showing - attendance - cumulative GPA. • 8th grade state assessment scores in Reading/Language Arts and Math • Math teacher recommendation, pages 5 • Science teacher recommendation, pages 6 • School counselor recommendation, pages 7

Keep the Information portion of the packet for future reference.

For additional information and to check eligibility, browse our website:

http://www.nwmissouri.edu/dept/ubms

Mail the Application packet (pages 1 - 7) postmarked on or before January 31 to:

Tanya M. Riley, Assistant Director

Upward Bound Math & Science Center Northwest Missouri State University

800 University Drive, AD 362 Maryville, MO 64468

(Do NOT mail this page.)

what is upward bound math science? - northwest … · upward bound math & science application -...

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