ACADEMIC VERIFICATION
Applicant Name:
First Name
Last Name
When evaluating the student, please keep in mind that students MUST have potential to succeed in post-secondary education and MUST demonstrate academic need for our services.
Counselor Name:
First Name
Last Name
School Name:
School Phone:
Format: (000) 000-0000.
Counselor Email:
example@example.com
Curriculum student is taking
General
USM Completer/College Bound
Honors
Other
What was the student's 8th grade Math Class?
8th grade Math
Algebra 1
Geometry
Other
What is the student's current Math Class?
What math class will the student be taking next year?
Has the student taken the MCAP Algebra 1
Yes
Not taken
Taking this year
If the student has taken the MCAP Algebra, what was their score?
Has the student taken the MCAP English 10
Yes
Not taken
Taking this year
If the student has taken the MCAP English 10, what was their score?
What is the student's 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 (select one):
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 specify
Students selected for UBMS must demonstrate a need for our services. How would you categorize the student's needs? Check all that apply.
Low GPA (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 accurate 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
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Next
Please select areas you feel the student could benefit from our services to improve Academic Skills:
Time Management
Note taking
Test Prep/Test Taking
Organization
Class Participation
Listening Skills
Attendance
Attitude
Please select areas you feel the student could benefit from our services to improve in Academic Content Areas:
Reading
Writing
Mathematics
Science
Social Studies
English/Language Arts
Please select areas you feel the student could benefit from Additional Supports:
Assistance with SAT/ACT preparation
Assistance with college selection
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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School Counselor Signature:
Date:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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