Eligibility Application

UBMS UPWARD BOUND MATH & SCIENCE

Upward Bound Math & Science Eligibility Application Hosted by Elizabethtown Community and Technical College

In order to be considered for program participation in the Upward Bound Math and Science program, please be sure to:

Complete each section of the application. Provide student signatures where requested.

After reviewing your eligiblity for the UBMS program you will receive:

Upward Bound Math and Science application, which you will need to have your Parents/Guardians complete.
Parent Income Verification Form

Please feel free to direct any questions to us at ectc.ubms@kctcs.edu

I. Please read the program and application information prior to completing the application.

2. Print clearly.

3. Answer each question completely.

4. Give special attention to directions in bold or parentheses.

Statement of Confidentiality: The personal information you give to the UBMS program is sent to the U.S. Department of Education. This information is protected by the Privacy Act. No one may see the information unless they work with or for the UBMS project or are specifically authorized to see the information. The information is necessary to determine your eligibility for participation and it helps the government measure our, and your, success.

First Name (Student)*

Last Name (Student)*

MI

REFERRAL INFORMATION: How did you hear about UBMS?*

Social Security #*

Birth Date:

Date

Age (Student *

Ethnicity: Are you Hispanic or of Latin descent?*

YesNo

Race: (choose all that apply)*

Citizenship Status: Please select on of the following*

I am a U.S. Citizen or national or permanent resident of the United States.I am in the United States for other than a temporary purpose and can provide evidence from the Immigration and Naturalization Service of my intent to become a permanent resident.I am a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands.I am a resident of the Freely Associated States - the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau.

SCHOOL CURRENTLY ATTENDING*

HIGH SCHOOL YOU WILL ATTEND IN 2024-2025 (if different from above)

CURRENT GRADE LEVEL*

EXPECTED HIGH SCHOOL GRADUATION YEAR*

HIGH SCHOOL ID # (if applicable)

CONTACT INFORMATION

It is very important that we can contact you and your parents. Please make sure that you provide accurate contact information.

Applications will NOT be considered if we cannot reach Parents | Guardians via contact information.

Student Personal Email Address *

Student School EMAIL ADDRESS *

example@example.com

Parent | Guardian EMAIL ADDRESS

Address*

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP

TELEPHONE: If no home/work phone number is available. you must provide an alternate name and number for messages. Home Telephone: ( Work Telephone: Alternative Telephone: ( [I Do you have access to social media?1Yes[No

Student Telephone*

Please enter a valid phone number.

Parent/Guardian Telephone*

Please enter a valid phone number.

Parent/Guardian Telephone*

Please enter a valid phone number.

Do you have access to social media?*

YesNo

Facebook Name

Does either of your parents/guardians have a four-year college degree (bachelor's degree)?*

YesNo

If yes, which parent (or both)?

What degree did they receive?

One of the criteria for admission to the UBMS program is meeting the income guidelines established by the U.S. Department of Education. Before UBMS can determine your son or daughter's eligibility, the program needs the following information. Please read carefully and complete all parts. If all information is not completed, the form cannot be processed. Please complete the following information as accurately as possible to determine economic eligibility. All information is kept confidential.

Was your family required to file a federal tax return?*

YesNo

Family Status*

SingleMarriedHead of Household/Single

Household size (including yourself)*

Please select the option which indicates your taxable family income last calendar year. (To determine this, refer to the "taxable income" line of your Federal tax return. Line 15 on the 1040 form. Taxable income IS NOT your gross or take home pay. Be sure to refer to your most recent tax return for this information. *

I certify that all of the information I have provided is valid and correct to the best of my knowledge. I understand that this is merely a form to determine my eligibility for admission into the program. Upon verifying my eligibility, I will be required to complete a UBMS admission application.

Student Name (Printed)*

Date*

Date

Student Signature*

Parent | Guardian Name (Printed)*

Parent| Guardian Signature*

Date*

Date

Please remember that this form serves to determine your eligibility. Once your eligibility has been determined, you will receive an Upward Bound Math and Science Application, which you will want to complete with your parents/guardians and return to UBMS staff.

APPLICATION DATE:

FINANCIAL INFORMATION