2025_26 UBMS STUDENT APPLICATION

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Name:*

Home Phone:*

Student Cell:*

Student Email (NOT school-issued):*

Birthdate:*

Date

Gender*

MaleFemale

Race/Ethnic Identification (check all that apply)*

Citizenship Status:*

US CitizenPermanant ResidentOther

Primary language(s) spoken by student:*

Student resides primarily with:*

Both Parents/GuardiansFatherMotherOther

Birthplace:*

Orphan or ward of the state?*

YesNo

How did you hear about UBMS?*

Current School:*

Current Grade

Current GPA:

School you will attend next year:*

How can UBMS help you? Check all that apply.*

What subjects do you enjoy MOST?*

What subjects do you enjoy LEAST?*

What are your career interests?*

T-shirt size for program-issued shirt (adult unisex sizes):

The Upward Bound Math Science program 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 your academic strengths and weaknesses are, what STEM careers interest you most, and how you feel we can help you. (Please take your time and tell us about yourself. We read them and use them as part of our evaluation process.)

Parent 1 Name:*

Address:*

Home Phone:*

Cell Phone:*

Email:*

Do you have a 4-year college degree?*

YesNo

Marital Status*

SingleMarriedSeparatedWidowed

Relationship to student:*

MotherFatherStepparentOther

Occupation:*

Primary language(s) spoken:*

Parent 2 Name:

Address:

Cell Phone:

Home Phone:

Email:

Do you have a 4-year college degree?

YesNo

Marital Status

SingleMarriedSeperatedWidowed

Relationship to student:

MotherFatherStepparentOther

Occupation:

Primary language(s) spoken:

If the student has a unique living situation (lives with grandparents, foster parents, etc.) please explain.

1) If you filed a federal tax return last year, answer the following with information from your most recent tax return.

All 8th-grade applicants must use the tax return from the year they will complete 8th grade.

You may submit a signed copy of your federal tax return in lieu of completing this section of the application. Copies of tax returns may be requested to verify application materials.

Tax Year Reported:

Filing Status

SingleMarried/JointlyMarried/Separately* (both parents taxable income and household sizes should be combined and reported)Other

Total number of household members listed on tax form:

Taxable Income- this is NOT total wages. This can be found on Line 15 of the IRS form 1040.

2) If you did not file a federal tax return last year, answer the following:

Did you receive Public Assistance? If yes, list the Case Number and Yearly Amount

Did you receive Social Security? If yes, list the Case Number and Yearly Amount

Did you receive Unemployment Compensation? If yes, list the Case Number and Yearly Amount

Did you receive other types of income? If yes, list the type and Yearly Amount

Is the student eligible for Free or Reduced Meals at school?*

YesNoUnsure

Parent/Guardian Signature:*

Household Member 1 (name, age)

Household Member 2 (name, age)

Household Member 3 (name, age)

Household Member 4 (name, age)

Household Member 5(name, age)

Household Member 6 (name, age)

Name of Emergency Contact 1*

Relationship to student:*

Phone (Day):

Phone (Evening):

Cell Phone:*

Name of Emergency Contact 2*

Relationship to student:*

Phone (Day):

Phone (Evening):

Cell Phone:*

Does the applicant have health insurance?*

YesNo

Name of Insurance Provider:

Policy Number:

Name of Family Doctor:

Doctor Phone:

Please upload any additional pages or information you wish to submit with your application.

Student Name:*

PARENTS AND STUDENT MUST READ AND SIGN: 
Upon request, Upward Bound Math/Science 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 US Department of Education requires the requested data of all current and former participants.  
I (we) understand that a student participating in Upward Bound Math/Science 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 Upward Bound Math/Science. 
In consideration of participating in Upward Bound Math/Science, 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 Upward Bound Math/Science. I (we) do myself, my heirs, and personal representatives, hereby defend, hold harmless, indemnify, and release the State of Maryland, the University, Upward Bound Math/Science, 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 Upward Bound Math/Science. 
I (we) understand that all participants must have a physical examination before participating in Upward Bound Math/Science. 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 Upward Bound Math/Science. 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 Upward Bound Math/Science. 
 
In signing this application, I (we) understand that my (our) son/daughter is applying for Upward Bound Math/Science. This year-round academic program includes a multi-week summer residential program at Frostburg State University AND an academic year component which primarily meets at target high schools, libraries in Frederick County, and virtually. I understand my (our) child is expected to meet the Academic Expectations of FSU UBMS students. 
 
I (we) will supply income verification information upon request.
I (we) will supply student citizenship or permanent residency verification upon request.
I (we) verify that I (we) have reviewed this application and the information given is correct to the best of my (our) knowledge.

Parent Signature:*

Student Signature:*

Upward Bound Math Science

Student Application

Applicant Essay

PARENT/GUARDIAN INFORMATION

Parent 1 Information

Parent 2 Information

CONFIDENTIAL INCOME CERTIFICATION

I certify that the income information given above is correct to the best of my knowledge.

Household

Emergency Contacts

Insurance Information

CONSENT FORM