Upward Bound Math Science
Applicant Name:
First Name
Last Name
Applicant Grade Level:
Counselor Name:
School:
School Phone:
Counselor Email:
example@example.com
School Rank if known ( ______ out of ______):
Curriculum
General
USM Completer/College Bound
Honors
Other
8th Grade Math Class
8th Grade Math
Algebra 1
Geometry
Other
Current Math Class
Next Math Class
HSA Math/Alg 1
Yes, Passed
Yes, Not Passed
Not Taken
Taking this year
HSA Reading/Lang Arts
Yes, Passed
Yes, Not Passed
Not Taken
Taking this year
Current Science Class
Does this student have an IEP?
Yes
No
Is the student performing at their expected ability level?
Yes
No
Given this student's grades and motivation, please rate their potential for success in post-secondary education:
Definite potential and motivation for success with little guidance and support
Potential and motivation are there, but the student will need guidance and support
The student has potential, but will need guidance and support to stay motivated
The student has motivation, but will need a lot of guidance and support to achieve academically
The student lacks potential and motivation, and post-secondary education is not realistic at this time
Other
Students selected for UBMS must demonstrate a need for our services. How would you categorize the student's needs? Check all that apply.
Low GP (below 2.5)
Limited English proficiency
Disconnected/homeless youth
No pre-algebra taken by the start of 10th grade
Taken and not passed Math/Alg 1 and/or Reading/Language Arts HSA
Low educational aspirations
Lack of opportunity, support, and/or guidance to take challenging college preparation courses
Lack of career goals or need for accurage information on careers
Lack of confidence, self-esteem, and/or social skills
Diagnosed learning disability
Predominantly low-income community
Rural isolation
Interest in careers in math and science
Other
Please select Academic Skill areas in which you feel the student could benefit from our services. Check all that apply.
Time Management
Note Taking
Test Prep/Test Taking
Organization
Class Participation
Listening Skills
Attendance
Attitude
Please select Academic Content areas in which you feel the student could benefit from our services. Check all that apply.
Reading
Writing
Mathematics
Science
Social Studies
English/Language Arts
Please select any Additional Supports in which you feel the student could benefit from our services. Check all that apply.
Assistance with SAT/ACT prepartaion
Assistance with college selections
Assistance with career development
Assistance with high school course selection
Assistance with self-development (i.e. motivation, self-esteem, communication skills, social skills)
Do you have any additional comments to make regarding this student's academic abilities and achievements that may have bearing on their acceptance into the UBMS program?
Please attach a copy of the student's complete transcript, current grades, and standardized test scores.
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