( Yes, Not Passed ( )Has the student taken their Algebra 1 High School Assessment? ( )Yes, PassedNot TakenWill 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.