Academic Verification Form

Academic Verification Form
Student Name
Student's 8th-grade math class:

Pre AlgebraAlgebra 1GeometryOther
Student's current math class
( Yes, Not Passed ( ) Has the student taken their Algebra 1 High School Assessment? ( )Yes, PassedNot Taken Will the student take their Algebra 1 High School Assessment this year? ) Yes ( )No
Has the student taken their Algebra 1 High School Assessment?

Yes, PassedYes, Not PassedNot Taken
Will the student take their Algebra 1 High School Assessment this year?

YesNo
What math class with this student take next year?
Given this student's grades and motivation, please rate their progress for success in a college mathematics or science program.

Definite potential for successPotential and motivation are there but the student will need a lot of guidance and supportStudent has the potential but lacks the motivationAt this point, it is not realistic for this student to consider pursuing a degree in mathematics or scienceOther
Students selected for the UBMS program must demonstrate a need for our services. How would you categorize this student's needs? Please check all that apply?

Need to improve GPANeed to increase confidence or self-esteemNeed to develop strong educational aspirationsNeed for additional opportunitiesNeed to develop career goalsNeed for support and or guidance to take challenging coursesPredominately low-income communityRural isolationInterest in Math and/or ScienceLimited proficiency in EnglishNeed to improve achievement test scores
Does this student have an IEP?

YesNoType option 3
Please select areas in which you feel the student could benefit from UBMS services:

Time managementNote takingTest prep & Test takingWriting skillsClass participationListening skillsAttendanceAttitudeOrganization
Do you have any additional comments that might assist us in evaluating this student's application?
Please attach a copy of the student's MOST RECENT GRADES and TRANSCRIPT- including STANDARDIZED TEST SCORES.

Cancelof
School Counselor's Name
School Name
School Phone
School Counselor's Email
example@example.com
School Counselor's Signature

Clear
Date

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Date
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