Part 1: Student Information
Name: (First, Middle, Last)
Address:
Street:
City: State: Zip:
Home Phone:
Alternative Phone: (Cell, Work, etc.)
E-Mail Address:
Date of Birth:
Gender:
Male Female
Citizenship: (I am a U.S. Citizen.)
Yes No
I am a Permanent Resident:
Yes No (If Yes, please include a copy of your card when submitting Part II of the application.)
I am neither. I have applied for citizenship.
Yes No (If Yes, copy of citizenship application must be included for consideration.)
Ethnicity:
Black /African American White American Asian American American Indian/Alaskan Native Latino/Hispanic American Native Hawaiian/Pacific Islander Other (Identify)
Current Grade:
9th 10th 11th
Name of High School:
High School Address:
High School Telephone Number:
Name of Your High School Counselor:
Counselor's Telephone Number:
When is the last day of school this year?:
If you have ever been enrolled in Upward Bound, Talent Search, or any other program that provides specialized educational programs/services, please complete the following:
Name of Program:
Name of Director:
Director's Telephone Number:
Please identify your sequence of math and science courses:
Math Courses
Last Year
Taking Now
Next Year
Algerbra
Geometry
Algebra II
Trigonometry
Precalculus
Science Courses
Physical Science
Environ. Science
Biology
Chemistry
Physics
Courses not listed above:
After graduating from high school I plan to:
Attend College Go into the Armed Services Find a job and work Undecided Other (Identify)
Part 3: Extracurricular Activities/Opportunities
List school and community clubs, organizations, and sports that you have been involved in since ninth grade. Identify awards or honors you have received. If you need additional space, attach another piece of paper.
Identify jobs or volunteer work you have done. You should include any church work, community service, and school or family jobs. Describe what skills you learned.
Describe any special interests or hobbies that you have. What do you after school and on weekends?
Have you applied to participate in any other summer programs, camps or opportunities?
Part 4: Parent-Guardian/Household Information: Father/Male Legal Guardian Information
Occupation:
Employer:
Work Phone:
Check the highest level of education father/male guardian achieved:
Did not complete high school High School Diploma Trade Certificate 2-Year College Degree 4-Year College Degree
Mother/Female Legal Guardian Information:
Father
Stepfather
Male Guardian
Other (Specify):
Mother
Stepmother
Female Guardian
Please list all members currently living in your household:
Name
Relationship
Age
Additional Family Members
Please list any family members who previously participated in the Upward Bound Math and Science Center Program:
Are you a ward of the court? Yes No
Part 5: Academic/Career Interests:
Please take time to think about your responses to the questions below before writing your answers. The best answers will be thoughtful and state in your own words.
Identify the academic and/or personal areas in which you believe our program can benefit you. Which UBMS services do you believe will be most valuable for you?
Identify TWO math- or science-related careers in which you could see yourself employed. Explain why you are interested in them.
Explain why you believe that you have the potential to successfully complete a math/science degree in college. Share as many specifics about yourself as you can.
Identify a current math/science TOPIC or ISSUE that you would be interested in researching further. Explain why. (NOTE: This is not a question about your career interests.)
Circle the appropriate number below to indicate your interest in math, science, and computers with 1 being "Not Interested" and 7 being "Very Interested".
Not Interested
Interested
Very Interested
4
5
7
Math
Science
Computers
Thank you again for your interest in this program. Online submissions will be directed to Joanne Nash, jln3. Feel free to contact me with questions or concerns at the above mentioned e-mail address or at my office at 800-596-4520.
