First Name *

Middle Name *

Last Name *

Preferred Name *

Street Address *

City *

State *

Zip Code *

Student Cell Phone Number *

Student Email Address *

Name of High School *

Current Grade Level *

Gender *

Student's Social Security Number *

Is the student a U.S. citizen? *

Is the student currently homeless? *

Is the student currently in foster care? *

Is the student currently in the juvenile court system? *

Has the student ever been in another Federally Funded College Access Program? *

Would you like the UBMS staff to contact your math OR science teacher as a reference? *

What is the first and last name of the teacher that you selected in the previous question? *

What is the email address of the teacher named in the previous question? *

What are the applicant's hobbies, club/organizations in school, sports etc. *

What is the student's dream job? *

Future Goals: Does the student plan to obtain an Associate's Degree (2 year)? *

Future Goals: Does the student plan to obtain an Bachelor's Degree (4 year)? *

Future Goals: Does the student plan to attend a vocational/trade school? *

Future Goals: Does the student plan to join the military out of high school? *

Future Goals: Does the student plan to join an ROTC military program in college? *

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Parent/Guardian 1 Relationship to Student *

Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Email Address *

Parent/Guardian 1 Occupation *

Does the student currently live with Parent/Guardian 1? *

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Relationship to Student

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Email Address

Parent/Guardian 2 Occupation

Does the student currently live with Parent/Guardian 2? *

Does Parent/Guardian 1 currently have a high school diploma or GED? *

Has Parent/Guardian 1 currently completed an Associate's Degree? *

Has Parent/Guardian 1 currently completed a Bachelor's Degree (or higher)? *

Does Parent/Guardian 2 currently have a high school diploma or GED? *

Has Parent/Guardian 2 currently completed an Associate's Degree? *

Has Parent/Guardian 2 currently completed a Bachelor's Degree (or higher)? *

Upward Bound Math-Science is a federally funded program that requires verification of family income for applicants. All information will remain confidential.

Total number of individuals living in student's household (including student). *

Parent/Guardian, did you file a federal income tax return for the most recent year? *

Parent/Guardian, what was the combined taxable income on your most recent taxes filed? *

Parent/Guardian, please sign to confirm the financial information recorded. *

Please select a signature verification type.

Parent/Guardian, please enter today's date along with your signature above. *

Student Commitment

The information provided above is accurate to the best of my knowledge. I understand that the goal of Upward Bound Math-Science is to help students prepare for college. I pledge that it is my desire to enroll in college upon graduation from high school.

*

Please select a signature verification type.

Student, please enter today's date along with your signature above. *

Parent/Guardian Commitment

As the parent/legal guardian of the student applicant, I verify that the information provided is accurate to best of my knowledge. I understand that the goal of the UBMS program is to help prepare my child for college. It is my desire for my child to attend college after completing high school. I also authorize the UBMS program to access my child’s official transcript and test scores through TRIAND.

Parent/Guardian, please sign to agree to the Parent/Guardian Commitment statement. *

Please select a signature verification type.

*