Upward Bound / Upward Bound Math Science Application

Upward Bound / Upward Bound Math Science Program Notice to Applicant
Please read the following information carefully before completing this application package.

The University of Georgia Upward Bound/Upward Bound Math & Science programs are federally funded projects with certain baseline eligibility guidelines which must be met by the applicant before further consideration can be given to the application. These criteria are as follows:

1 Applicant must be potential first-generation college students, meaning both parents have not obtained a

2 Applicants must be from a working-class family. The term “working class individual” means an individual from a family whose taxable income for the preceding year did not exceed 150 percent of the poverty level established by the Census Bureau.

3 Applicants must be currently enrolled in high school in one of the program target schools listed below.

Please Feel Free to contact our office at (706) 542-4128 with any questions and we look forward to receiving your application.

Sincerely,

Sonia Davis

UB/UBMA Program Director

Student Information
In order to be considered for program participation, each student must complete this application.
Full Name (First Middle Last)*
Student Age*
Gender

MaleFemale
Ethnicity*
Place of Birth (City and State)
Birth Date*

MonthDayYear
Date
Are you a US Citizen?*

Yes:No
Curent Grade*

9th10th11th12th
High School Name*
Student Cell Phone Number

Area CodePhone Number
Student Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Emergency Contact Person Name*
Emergency Contact Person Phone #*

Area CodePhone Number
Emergency Contact Person Email address*
example@example.com

Parent/Guardian Information

To be completed about/by a parent or guardian.
Relationship to Student*
Guardian Employer*
Guardian First Name*
Guardian Last Name*
Guardian Mailing Address*
Guardian Home Phone #

Area CodePhone Number
Guardian Cell Phone #

Area CodePhone Number
Guardian Work Phone#

Area CodePhone Number
Guardian Email Address
example@example.com
Guardian Employment Title
Did Parent/Guardian finish high school?*

YesNo
Did Parent/Guardian attend college?*

YesNo
Did Parent/Guardian attend complete a 4 year college degree?*

YesNo
Guardian Years Lived in Georgia
Guardian; What is your estimated gross monthly salary?*
Guardian; What is your estimated gross yearly salary?*
Date

MonthDayYear
Date
I certify that the information listed above concerning guardian one, including any financial information is accurate and true to the best of my knowledge. (Guardian 1 should sign below)*

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Other Information
Does your child suffer from any physical problems, learning disabilities, or are they currently on an IEP?
Please describe any hardships or circumstances which you feel we should consider?
Please list school administrators and teachers below who could recommend you for Upward Bound | Upward Bound Math & Science
School Counselor Name
Science Teacher Name
History Teacher Name
Math Teacher Name
English Teacher Name

Program Releases

Please read each statement and sign. Pay attention to if the student or guardian signature is required.
The student signature below indicates that, to the best of their knowledge, the information provided on this application is true, complete, and accurate. I also authorize Upward Bound / Upward Bound Math & Science to obtain copies of any of my academic records from the educational institutions I now attend, have attended in the past, or will attend in the future, including the college or university in which I enroll following my high school graduation. Student Signature*

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Student Signature
Date

MonthDayYear
Date
The guardian signature below indicates that, to the best of my knowledge, the information provided on this application is true, complete, and accurate. I also authorize Upward Bound / Upward Bound Math & Science to obtain copies of any of my academic records from the educational institutions I now attend, have attended in the past, or will attend in the future, including the college or university in which I enroll following my high school graduation. Parent/Guardian Signature*

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Parent\Guradian Signature
Date

MonthDayYear
Date
(Parent) I hereby give permission to the school named on this application to release a copy of our application for free and reduced meals to the Upward Bound / Upward Bound Math & Science for the purpose of verifying any information provided on the application. Parent/Guardian Signature:*

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Parent\Guardian Signature
Date

MonthDayYear
Date
Permission and Release
I hereby give permission for , (Student Name listed below) if selected, to participate in the Upward Bound / Upward Bound Math & Science approved activities college tours, field trips, etc.*
Type student full Legal Name
(Student) I understand that, if selected, he/she will be required to attend four Saturday Academies during the regular academic year and to attend the Upward Bounds / Upward Bound Math & Science summer program held at the University of Georgia. I also agree to support his/her compliance with rules and regulations of the University of Georgia and the Upward Bound / Upward Bound Math & Science program and staff. I relieve the University of Georgia and the Upward Bound / Upward Bound Math & Science program of any claims and liabilities which may arise directly or indirectly when participating in the program. I agree that all photographs of the student taken during the program, papers written by the student during the program, and similar items may be used by the Upward Bound / Upward Bound Math & Science in reports, other public information materials and venues including the Program’s newsletter, social media, and official websites. Student Signature*

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Student Signature
Date

MonthDayYear
Date
(Guardian) I understand that, if selected, he/she will be required to attend four Saturday Academies during the regular academic year and to attend the Upward Bounds / Upward Bound Math & Science summer program held at the University of Georgia. I also agree to support his/her compliance with rules and regulations of the University of Georgia and the Upward Bound / Upward Bound Math & Science program and staff. I relieve the University of Georgia and the Upward Bound / Upward Bound Math & Science program of any claims and liabilities which may arise directly or indirectly when participating in the program. I agree that all photographs of the student taken during the program, papers written by the student during the program, and similar items may be used by the Upward Bound / Upward Bound Math & Science in reports, other public information materials and venues including the Program’s newsletter, social media, and official websites. Parent/Guardian Signature*

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Parent\Guardian Signature
Date

MonthDayYear
Date
UNIVERSITY of GEORGIA Upward Bound/Upward Bound Math-Science Program 103 Hooper Street 321 Milledge Hall Athens Georgia 30602
Should be Empty:

Upward Bound / Upward Bound Math Science Program Notice to Applicant

Student Information

Education Plans:

Summer Components of Upward Bound/Upward Bound Math Science are Mandatory!

Parent/Guardian Information

Financial Information – Statement of Confidentiality

Other Information

Please list school administrators and teachers below who could recommend you for Upward Bound | Upward Bound Math & Science

Program Releases

Permission and Release

UNIVERSITY of GEORGIA Upward Bound/Upward Bound Math-Science Program 103 Hooper Street 321 Milledge Hall Athens Georgia 30602