KU UBMS Online Application Form

KU Upward Bound Math Science Application Form

Parent/Guardian Information
Parent/Guardian's Information
Female Guardian
Male Guardian
Parent/Guardian's Name - Primary

First NameLast Name
Parent/Guardian's Email Address:
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
Best time to contact:

MorningAfternoonEvening
Any other language than English spoken at home?*

YesNo
Language spoken:

First Generation Eligibility
First Generation Eligibility Information
Has either parent/guardian graduated from college with a 4-year degree?*

YesNo
If yes, which parent/guardian?*
Degree(s) earned:*

Enrollment Information
Enrollment Information

You will need to provide a copy of your transcript.
Current Grade*

9101112
Current School*

Leavenworth High SchoolTurner High SchoolOther
Current Class Schedule*
Upload your transcript here:
Please upload a copy of your transcript here:

Tax return
Cancelof

Academic Need

Please give your honest opinion of how the Upward Bound Math Science-LT program can meet your needs: *

	No Need	Some Need	High Need
To learn how to complete and turn in my homework on time
To get better grades in school
To take tests better with less anxiety
To organize my time, activities, and responsibilities better
Learn more about high school requirement for college
Listen better in class and ask more questions
To relate to and communicate better with my teacher
To identify, set and evaluate goals for the future

My academic goal is:*

	No Need	Some Need	High Need
To explore a variety of career opportunities
To learn more about job applications, resumes, and interviews
To learn more about the postsecondary admissions process
To prepare for exams like the ACT and SAT
To visit more colleges
To learn about college costs and how to pay for college

My career goals are:*
Write a short paragraph stating how you would benefit from participating in the Upward Bound Math Science-LT program:
Consent of Release of Educational Information

I agree to the release of my/my student’s grades, standardized test scores and transcripts by my middle school and/or high school to the University of Kansas Upward Bound Math Science-LT Program beginning on the date of application. I understand that the Upward Bound Math Science-LT Program will also maintain records on my performance in program activities. I agree to the release of this information to staff members and the U.S. Department of Education.
Student Name:*

First NameLast Name
Parent/Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Date
Electronic Media Release

Release for Electronic Work, Photos, and Video. I authorize the Achievement and Assessment Institute and its four Centers (the Center for Educational Testing and Evaluation, the Center for Public Partnerships and Research, the Center for Educational Opportunity Programs, and Agile Technology Solutions) to use photos or videos of my child/children for the following purposes:
As illustration on project materials for educational purposes and on the websites of the Upward Bound Math Science, the Achievement and Assessment Institute and its four Centers.*

Yes, I authorizeNo, I do not authorize
Please select your preference:*

I give the Achievement and Assessment Institute and the four Centers permission to use my child/children’s real names for project materials and on the website.I prefer that the Achievement and Assessment Institute and the four Centers use pseudonyms for my child/children in project materials and on the website.
I hereby acknowledge that I am the parent/guardian of the below listed child/children. I hereby give the above permission, and I release the Achievement and Assessment Institute and the four Centers from any liability resulting from the publication of said photos, videos, or comments. I understand that all photography and video recording will be related to the work of the Achievement and Assessment Institute and its four Centers.
Student Name:*

First NameLast Name
Parent/Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Date

Parental Consent to Participant
I hereby grant permission for my child, First Name Last Name , to participate in the University of Kansas Upward Bound Math Science program-LT, which may include field trips, overnight trips, tutorial sessions, living in the residential halls, and physical activities. I also understand and acknowledge that transportation for field trips for academic enrichment sessions, conferences, overnight trips, and other activities will be provided by bus, van, train, airplane, or private car. Activities may include swimming, canoeing, horseback riding, and other activities. In consideration of the activities provided to my child, I hereby release the University of Kansas Upward Bound Math Science-LT program and their employees from any claims of injury or damages arising out of my child’s participation. I accept responsibility for my child’s conduct while participating in the Upward Bound Math Science-LT Program, and I hereby release the Upward Bound Math Science-LT Program from injuries or damages resulting from my child not following and adhering to the rules and policies of the program.
Parent/Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Date
We agree that all the information contained in this application is true and correct. I understand that my guidance counselor should attach a copy of my school grades and test scores before sending my application. In addition, I pledge that if I am accepted into the University of Kansas Upward Bound Math Science-LT Program, I will conform to the following requirements:*

I will abide by all rules and policies of the program.I will attend Saturday Enrichment Sessions, Summer Institutes, and other required events on a regular basis.I will strive to continually improve my high school course grades.I will make every effort to pass all high school course work.I will cooperate with faculty, staff, and other students in the program.I will make every attempt to remain in the program for the remainder of my high school education.I will enter a postsecondary educational study program upon completion of the Upward Bound Math Science-LT Program.
Student Signature:*

Clear
Parent/Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Date

Confidential Health Record
Student Name*

First NameLast Name
SSN
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name:*

First NameLast Name
Home Phone Number*
Please enter a valid phone number.
Person to be notified in case of an emergency (if other than above):*

First NameLast Name
Day Phone Number*
Please enter a valid phone number.
Evening Phone Number*
Please enter a valid phone number.

	Yes or No	If yes, please list
Do you have any significant illness or disability?
Have you had any other significant illness, injuries, or surgery in the past?
Are you allergic to any medications, or do you have any allergies?
Are you under medical care, including current prescriptions?

Insurance Release
Does the student have health insurance?*

YesNo
Name of Insurance Company:
Address of Insurance Company:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to policy holder:
Address of policy holder:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy holder individual ID number:
Policy holder group number:

Medical Release
Medical Release
Please select the following:*

I hereby authorize Watkins Health Center and/or Lawrence Memorial Hospital to release primary and secondary diagnoses and/or accident details to the provided insurance company. If there is no company listed, release information to Upward Bound Math-Science’s summer insurance provider as necessary. Also, release information presenting my claim for benefits, as requesting by such company for the purpose of considering my claim.I hereby authorize payment directly to Watkins Health Center and/or Lawrence Memorial Hospital of the benefits otherwise payable to me. I understand that I am financially responsible to Watkins Health Center and/or Lawrence Memorial Hospital for charges not covered by insurance.I hereby authorize payment directly to Watkins Health Center and/or Lawrence Memorial Hospital of the benefits otherwise payable to me. I understand that I am financially responsible to Watkins Health Center and/or Lawrence Memorial Hospital for charges not covered by insurance.
Student Signature:*

Clear
Parent/Guardian Signature:*

Clear
Should be Empty:

KU Upward Bound Math Science Application Form

Student Information

Parent/Guardian's Information

First Generation Eligibility Information

Financial Eligibility Information

Enrollment Information

Consent of Release of Educational Information

Electronic Media Release

Medical Release