Upward Bound Math/Science 2024-25 Application

First*

MI*

Last*

Preferred Name*

Preferred Pronoun:*

he/him/hisshe/her/hersthey/them/theirsOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Cell Phone*

Student E mail Address (Personal email such as gmail, hotmail, etc. NOT A SCHOOL EMAIL)*

example@example.com

Student's Birthdate*

Date

Sex*

MaleFemaleOther

Citizenship*

United StatesPermanent ResidentNon-Citizen

Race/Ethnic Identification: check all that apply*

Current School:*

Current Grade:*

8th9th10th11th

Guidance Counselor*

School you will attend next year*

What subjects do you enjoy MOST?*

What subjects do you enjoy LEAST?*

Career Interest*

How can we help you?*

Study SkillsTest TakingAcademic Challenge

Please indicate if you are a member of any of these programs:*

Please indicate which size t-shirt (men's sizes) we should order for you:*

Is this student an orphan or ward of the court?*

YesNo

Essays help us learn about you and are part of our evaluation process when selecting participants. Please take your time and tell us about yourself. You may attach a separate sheet if you need more space. The Upward Bound RMSC is a pre college program designed to help high school students prepare for post secondary education in programs leading to STEM degrees and careers. Tell us why you are interested in our program, what your plans are after graduating high school, what STEM careers interest you most, and how you feel we can help you.*

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone*

Home Phone*

Please enter a valid phone number.

Occupation*

Do you have a four-year college degree?*

YesNo

Email Address*

example@example.com

Marital Status*

SingleMarriedSeperatedWidowed

Relationship to student:*

MotherFatherStepparentOther

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone

Please enter a valid phone number.

Home Phone

Please enter a valid phone number.

Occupation

Do you have a four-year college degree?

YesNo

Email Address

example@example.com

Marital Status:

SingleMarriedSeparatedWidowed

Relationship to student:

MotherFatherStepparentOther

If the student has a unique living situation (lives with grandparents, foster parents, etc.) please explain

If TAXABLE Income was zero, please indicate this by entering $0. If you are providing information for two parents who file separately, please record the combined family size and taxable income.

Which Tax Year are you providing (2023 or 2024)? Applications received after Monday, April 15, 2024, must submit 2024 tax information.

Total number of household members (claimed on tax form)?

What was your TAXABLE INCOME (IRS 1040-line 15 on 2023 form)?

If no income tax was filed, was Public Assistance received (list Case Number and Yearly Amount)

If no income tax was filed, was Social Security received (list Case Number and Yearly Amount)

If no income tax was filed, was Unemployment Compensation received (list Case Number and Yearly Amount)

If no income tax was filed, was Child Support received (list Case Number and Yearly Amount)

If no income tax was file, was there any additional income (list type and Yearly Amount)

Is the student eligible for Free and Reduced Meals at school?*

YesNoUnsure- have not applied

Parent/Guardian Signature: I/We certify that the above income information is correct to the best of my knowledge and I/We understand that the information supplied will be kept confidential and is required by the United States Department of Education, the funding sources of the Upward Bound Math/Science to determine eligibility.*

Date*

Date

Parent/Guardian Signature: I/We certify that the above income information is correct to the best of my knowledge and I/We understand that the information supplied will be kept confidential and is required by the United States Department of Education, the funding sources of the Upward Bound Math/Science to determine eligibility.

Date

Family Member 1 (Name & Age)

Family Member 2 (Name & Age)

Family Member 3 (Name & Age)

Family Member 4 (Name & Age)

Family Member 5 (Name & Age)

Family Member 6 (Name & Age)

Family Member 7 (Name & Age)

Family Member 8 (Name & Age)

Emergency Contacts (other than parent/guardian):

Emergency Contact 1 Name*

Emergency Contact 1 Relationship*

Emergency Contact 1 Phone*

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Phone

Applicant's Full Name*

PARENTS AND STUDENT MUST READ AND SIGN:

Upon request, Upward Bound Math/Science may secure copies of any and all subsequent information and materials relative to the applicant's academic performance, including both high school and college/university transcripts and financial aid information.
I (we) realize that the requested data is required by the US Department of Education of all current and former participants. I (we) understand that this consent form is good for 12 years. I (we) understand that a student participating in Upward Bound Math/Science will be engaged in certain educational and recreational activities, including but not limited to camping, hiking, canoeing, and initiative activities that come with the risk of physical injury. I (we) understand also that various field trips to off-campus locations may be taken under the supervision of Upward Bound Math/Science.

In consideration of participating in Upward Bound Math/Science, I (we) understand that Frostburg State University (the "University") shall, in no way, be deemed responsible for the operation, safety, and management of any means of transportation, public or private, or off-campus facilities used while participating in Upward Bound Math/Science. I (we) do myself, my heirs, and personal representatives, hereby defend, hold harmless, indemnify, and release the State of Maryland, the University, Upward Bound Math/Science, and all its officers, agents, and employees from and against all claims, demands, and actions, or causes of action, on account of damage to personal property, personal injury, or death which may result from my (our) participation in Upward Bound Math/Science.

I (we) understand that all participants must have a physical examination before participating in Upward Bound Math/Science. I (we) understand that (we) am solely responsible for determining whether the participant has any physical or mental limitations preventing him or her from participating in Upward Bound Math/Science. I (we) further understand that the University has no actual or constructive notice of any such limitation, and hereby release the State of Maryland, the University, and its officers, agents, and employees, from any liability arising from any injuries from such limitation.
I (we) give consent for the participant to receive routine and/or emergency medical services (if needed) for the participant's entire enrollment period in Upward Bound Math/Science.
I (we) understand that pictures of participants are routinely used in promotional and program materials such as newsletters, videos, web pages, calendars, etc.
I (we) will indicate in writing if we do NOT want our child's picture used in such materials.
I(we) understand that Upward Bound Math/Science staff will be working with my student throughout the academic year and I (we) give permission for the staff to meet with my student at his/her home school.

Insigning this application, I (we) understand that my (our) son/daughter/ward is applying for Upward Bound Math/Science, a year-round academic program which includes a multi-week summer residential program at Frostburg State University and an academic year component, and that my (our) child/ward is expected to participate in both components.

I (we) will supply income verification information.
I(we) verify that (we) have reviewed this application and the information given is correct to the best of my (our) knowledge.
I (we) understand that information supplied in this application will be confidential and is required by the United States Department of Education, the funding source.

Parent/Guardian Signature & Date*

Date

Parent/Guardian Signature & Date

Date

Student Signature & Date*

Date

Upward Bound Math/Science

Parent 1 (or guardian)

Parent 2 (or guardian)

Income Certification

Other Family Information

Emergency Contacts (other than parent/guardian)

Upward Bound Math/Science Consent Form