Upward Bound : RMSC Application

Upward Bound RMSC

Regional Math/Science Center at Frostburg State University
STUDENT APPLICATION

Student Information
First Name
Middle Initial
Last Name
SSN
Preferred Name
Type a question

he/him/his she/her/hers they/them/theirs Other
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Cell Phone
Student E mail Address
example@example.com
Birth date

Month Day Year
Date
Student Sex:

Male Female Other
Citizenship

United States Permanent Resident Non Citizen
Race/Ethnic Identification: check all that apply

Asian/Indian American Indian/Alaskan African American/Black Caucasian/White Hawaiian/Pacific Islander Hispanic/Latino Other
Current School
Current Grade

8th 9th 10th 11th
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? Check all that apply

Study Skills Test Taking Academic Challenge
Please indicate if you are a member of any of these programs:

Upward Bound Talent Search GEAR UP AVID
Please indicate which size t-shirt (men's sizes) we should order for you:

small medium large x-large Other
Is the student an orphan or ward of the court?

Yes No
Applicant Essay
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.
Parent Information
Parent 1 (or guardian)
First name
Last name
Address (Street, City, State, Zip)
Cell Phone Number
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Occupation
Do you have a 4-yr college degree (Bachelors Degree)?

Yes No
Email Address
example@example.com
Marital Status

Single Married Separated Widowed
Relationship to student

Mother Father Stepparent Other
Parent 2 (or guardian)
First name
Last name
Address (Street, City, State, Zip)
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Occupation
Do you have a 4-year college degree (Bachelors Degree)?

Yes No
Email Address
example@example.com
Marital Status

Single Married Separated Widowed
Relationship to student:

Mother Father Stepparent Other
If the student has a unique living situation (lives with grandparents, foster parents, etc.) please explain
CONFIDENTIAL INCOME CERTIFICATION

To be completed by parent or guardian
If TAXABLE Income was $0, please indicate this by entering $0. If youare providinginformation fortwo parents who file separately, please record the combined family size and taxable income.

If you filed a federal income tax return last year:
Tax Year
Total number of household members (claimed on tax form)
What was your TAXABLE INCOME (IRS 1040-line 15)
If no income tax return was filed:
Public Assistance case number: blanks
Yearly amount received:blank
Social Security case number: blanks
Yearly amount received: blank
Unemployment Comp. case number: blanks
Yearly amount received: blank
Child Support case number: blanks
Yearly amount received: blank
Any other forms of income:
Case number for other income if applicable: blanks
Yearly amount received:blank
Is the student eligible for Free and Reduced Meals at school?

Yes No Unsure
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 RMSC to determine eligibility.
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Household Members

Please list the names and ages of members of the applicant's household
Member 1: Name blanks Age blank
Member 2: Name blanks Age blank
Member 3: Name blanks Age blank
Member 4: Name blanks Age blank
Member 5: Name blanks Age blank
Member 6: Name blanks Age blank
Member 7: Name blanks Age blank
Member 8: Name blanksAge blank
Emergency Contacts (other than parent/guardian):
Emergency Contacts

Other than parent/guardians
Name
Relationship
Phone
Name
Relationship
Phone
CONSENT FORM

A paper copy of this form and a postage paid envelope will be mailed signatures on this form in addition to this digital application.
Consent valid 01/01/2022 to 01/01/2034
Student Name
PARENTS AND STUDENT MUST READ AND SIGN:
- Upon request, the Regional Math/Science Center 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 the Regional Math/Science Center 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 the Regional Math/Science Center.
- In consideration of participating in the Regional Math/Science Center, 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 the Regional Math/Science Center. I (we) do myself, my heirs, and personal representatives, hereby defend, hold harmless, indemnify, and release the State of Maryland, the University, the Regional Math/Science Center, 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 the Regional Math/Science Center
  - I (we) understand that all participants must have a physical examination before participating in the Regional Math/Science Center. I (we) understand that I (we) am solely responsible for determining whether the participant has any physical or mental limitations preventing him or her from participating in the Regional Math/Science Center. 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 the Regional Math/Science Center.
  - 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 that the RMSC 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.
In signing this application, I (we) understand that my (our) son/daughter/ward is applying for the Regional Math/ Science Center, 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 I (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

Clear
Parent/Guardian Signature & Date

Clear
Student Signature & Date

Clear
Should be Empty:

Upward Bound RMSC

STUDENT APPLICATION

Applicant Essay

Parent Information

CONFIDENTIAL INCOME CERTIFICATION

If no income tax return was filed:

Household Members

Emergency Contacts

CONSENT FORM

PARENTS AND STUDENT MUST READ AND SIGN: