Upward Bound Math & Science Program Program Application

Dear Applicant:

If you are currently in ninth or tenth grade and interested in a career in the fields of math or science, the

Indian River State College Upward Bound Math and Science Program (UBMS) may be for you. To qualify,

eligible students must meet federal income eligible guidelines and/or live with parents/guardians who have

not received a four-year college degree or exhibit a strong academic need for the program services. It is

important that you understand that participation in the Upward Bound Math and Science Center at Indian

River State College requires that you participate in all UBMS activities, assignments, and services provided

during the following school year and attend the six-week summer session if chosen. By submitting this

application, you are indicating that you are aware of and agree to these commitments if selected. We are very

pleased that you are interested in UBMS. Attached are the forms you will need to complete in order to be

considered for participation. Please be aware that ALL questions need to be answered and ALL forms

must be received for your application to be considered.

YOUR APPLICATION MUST INCLUDE THE FOLLOWING TO BE COMPLETE:

High School Transcript - including current grades and grade-point average (GPA). You can obtain this from your

guidance office.

FCAT Scores – For Math, Reading, and Writing for 8th grade or 10th grade. You can obtain this from your

guidance office.

Financial Documents - a copy of the first two pages of your family’s last Federal Income Tax Return (IRS Form

1040, 1040A or 1040EZ, or other appropriate documentation (see page 7) if a tax return was not completed.

Three Recommendation Forms - one from your math instructor, one from your science instructor and one from

your guidance counselor. These forms are located inside.

This Application Form - completely filled out and signed where appropriate.

Copy of SS Card

Completed IRSC Application & College Placement Test Scores

You will be notified upon receipt of your application. If you have any questions, please call our office at 772-462-

7237. Thank you for taking the time to complete this application thoroughly.

Completed applications must be submitted by:

PART 1: STUDENT INFORMATION

To Student: The application must be typewritten or printed neatly in blue or black ink. Answer all questions; failure to do so will delay the

processing. If a question is not applicable, mark “N/A” in the space provided.

To parent or legal guardian: The personal information, including financial status and educational levels, given to the Upward Bound Math and

Science is used for reporting purposes with the United States Department of Education. No one may access, view or utilize the information

unless they work with or for Upward Bound Math and Science or unless they are given specific or legal authorization to said information. This

information is required to determine if your child meets federal eligibility guidelines established by regulation of the United States Department of

Education. All information is protected under the Family Educational Rights and Privacy Act (FERPA, 20 USC 1231a).

Name LAST FIRST M I

Address STREET APT. #

City ____________________________________ State ___________________________ Zip

Home Phone: Soc. Sec. No.: ___________-________-________ Collection of Social Security numbers is required for federal reporting purposes under Title IV, Section 402A(c)(2) and section 402C of the

Higher education Act of 1965, as amended; the program regulations in 34CFR Part 645; and 34 CFR Sections 75.590 and 75.720 of the

Education Department general Administrative Regulations (EDGAR).

Student’s Cell # :______________________ Student’s E-mail Address :_________________________________________ Date of Birth: ________________________________ Gender: Male Female

Current School

If you are an 8th grader, name of high school you plan to attend

Are you currently a participant of: Upward Bound Educational Talent Search

If yes, name and phone number of program director

NAME PHONE NUMBER

What languages are spoken in your home?

What is the preferred language of your parents or guardians?

Are you a US Citizen? Yes No

If you are not, are you a Resident Alien? Yes No

NOTE: You must be a US citizen or legal resident of the United States in order to participate in and receive services from Upward Bound Math

and Science. If you are not a US citizen, enter your Alien Registration Number. If your number is only eight digits, enter a zero after the “A”.

I am neither. I have applied for citizenship. * Yes No *(copy of citizenship application must be included for consideration) ETHNICITY: Hispanic Non-Hispanic

RACE

Black/African American Native Hawaiian/Pacific Islander

American Indian/Alaskan Native Asian American White American

Other (Identify) _______________________________________________

How did you hear about Upward Bound Math and Science?

______________________________________________________ _______________________________________ Student Signature Date

Alien Registration Number

PART 2: SCHOOL/ACADEMIC INFORMATION

Current Grade in School: 9th 10th 11th Name of High School: Name of Your High School Counselor: Counselor’s Phone No.: ( ________)

Please check your sequence of math and science courses:

Last Taking Next Last Taking Next

Math Courses Year Now Year Science Courses Year Now Year

Algebra ο ο ο Physical Science ο ο ο

Geometry ο ο ο Environ. Science ο ο ο

Algebra II ο ο ο Biology ο ο ο

Trigonometry ο ο ο Chemistry ο ο ο

Pre-calculus ο ο ο Physics ο ο ο

Courses not listed above: ___________________________________________________________________

After graduating from high school what are your educational plans: (Check the statement(s) which best describe(s) your present plans)

I plan to go to work full-time after high school graduation.

I plan to enter military service after high school graduation.

I plan to complete an associate’s degree (2 years of community college) after high school graduation.

I plan to complete a bachelor’s degree (4 years of university) after high school graduation.

I am currently undecided about my educational plans after high school graduation.

Educational Plans – List in order of preference, two occupations you think would best fit your abilities and interests if you were

given the necessary education and required training:

1.

2.

PART 3: EXTRACURRICULAR ACTIVITIES/OPPORTUNITIES

List school and community clubs, organizations, and sports that you have been involved in since ninth grade.

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Identify awards or honors you have received. If you need additional space, attach another piece of paper.

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Identify jobs or volunteer work you have done. You should include any church work, community service, and school or

family jobs. Describe what kind of skills you learned.

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Describe any special interests or hobbies that you have. What do you do after school and on weekends?

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Have you applied to participate in any other summer programs, camps or opportunities? Please list them below.

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PART 4: PARENT-GUARDIAN/HOUSEHOLD INFORMATION

FATHER / MALE LEGAL GUARDIAN:

Name: ______________________________________________________________________________________

First Last M I

Home Address: _______________________________________________________________________________ STREET CITY STATE ZIP

Occupation: _____________________________Employer: ____________________________________________

Work Phone: (___) _____________________________Email:__________________________________________

Home Phone: (______) ____________________________ Cell: (______) ________________________________

Check the highest level of education father/male guardian achieved:

Did not complete high school High School Diploma Trade Certificate

2-year college degree 4-year college degree

MOTHER / FEMALE LEGAL GUARDIAN:

Name: ______________________________________________________________________________________

First Last M I

Home Address: _______________________________________________________________________________ STREET CITY STATE ZIP

Occupation: _____________________________Employer: ____________________________________________

Work Phone: (___) _____________________________Email:__________________________________________

Home Phone: (______) ____________________________ Cell: (______) ________________________________

Check the highest level of education mother/female guardian achieved:

Did not complete high school High School Diploma Trade Certificate

2-year college degree 4-year college degree

I currently live with (check all that apply):

Father Stepfather Male guardian Other (specify): _____________________

Mother Stepmother Female guardian Other (specify): _____________________

Please list all members currently living in your household:

Name Relationship Age _____________________________ ____________________________ ____________________

_____________________________ ____________________________ ____________________

Please list any family members who previously participated in the Upward Bound Math and Science Program:

Name Relationship Age _____________________________ ____________________________ ____________________

_____________________________ ____________________________ ____________________

Are you a ward of the court? Yes No

PART 5: ACADEMIC/CAREER INTERESTS

PLEASE NOTE: IF YOU ARE APPLYING, YOU WILL NEED TO COMPLETE THE LIST OF QUESTIONS BELOW. YOUR ANSWERS WILL NEED

TO BE A MINIMUM OF 4 TO 5 SENTENCES PER EACH QUESTION. IN ADDITION, WE HOPE TO GAIN A BETTER UNDERSTANDING OF YOUR

ACADEMIC AND CAREER INTERESTS. IF YOU NEED ADDITIONAL SPACE, ATTACH ANOTHER PIECE OF PAPER.

Identify the academic and/or personal areas in which you believe our program can benefit you. Which UBMS services do you believe will be most valuable for you? _________________________________________________________________________________________________________

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Identify TWO math- or science-related careers in which you could see yourself employed. Explain why you are interested in them.

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PART 5: ACADEMIC/CAREER INTERESTS CONT.

PLEASE NOTE: IF YOU ARE APPLYING, YOU WILL NEED TO COMPLETE THE LIST OF QUESTIONS BELOW. YOUR ANSWERS WILL NEED

TO BE A MINIMUM OF 4 TO 5 SENTENCES PER EACH QUESTION. IN ADDITION, WE HOPE TO GAIN A BETTER UNDERSTANDING OF YOUR

ACADEMIC AND CAREER INTERESTS. IF YOU NEED ADDITIONAL SPACE, ATTACH ANOTHER PIECE OF PAPER.

Explain in a complete sentence as to why you believe that you have the potential to successfully complete a math/science degree in college. Share as many specifics about yourself as you can. _________________________________________________________________________________________________________

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Identify a current math/science TOPIC or ISSUE that you would be interested in researching further. Explain why. (NOTE: This is not a question about your career interests.) _________________________________________________________________________________________________________

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Circle the appropriate number below to indicate your interest in math, science, and computers. Not Interested Interested Very Interested

Math 1 2 3 4 5 6 7

Science 1 2 3 4 5 6 7

Computers 1 2 3 4 5 6 7

PART 6: FINANCIAL INFORMATION

THE UPWARD BOUND MATH AND SCIENCE PROGRAM IS A FEDERALLY FUNDED PROGRAM. FOR THE APPLICANT TO QUALIFY, VERIFICATION OF INCOME IS NECESSARY.

ALL INFORMATION IS CONFIDENTIAL AND FOR PROGRAM USE ONLY.

IF YOU FILE A TAX RETURN:

What was your family's total annual TAXABLE (line 43 on IRS forms 1040) income for last year? $_____________ (If you have not completed a tax form for the 2009 year, you may use the figures from the form you filed for 2008)

How many family members (adults and children) are living in the household? _____________________ PLEASE NOTE: A SIGNED copy of page 1 & 2 from your IRS tax form 1040, 1040A or 1040ez, which documents the TAXABLE INCOME identified above, must accompany this application. (See example below)

IF YOU DO NOT FILE A TAX RETURN: (If this applies to you, please indicate below)

I certify that I am not required to file a federal income tax return and my total household income for the 2009

tax year was $________________________.

_____________________________________________ Parent Signature

Identify the source and amount of your nontaxable income. *Documentation of the sources of income must be submitted for the application to be considered.

MONTHLY MONTHLY

ο AFDC(Public Assistance) $____________________ Disability/SSI $_________________ Unemployment $ ____________________________ Retirement/Pension $__________________ Social Security $____________________________ Veterans Benefits $___________________ Other (specify): $ ___________________________

X PLEASE SIGN

PART 7: PARENT COMMITMENT STATEMENT I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT MY CHILD IS REQUIRED TO ALL UBMS ACTIVITIES AND EVENTS UNTIL HIS/HER GRADUATION FROM HIGH SCHOOL. I UNDERSTAND THAT MY INVOLVEMENT AND SUPPORT IS CRITICAL IN MY STUDENTS SUCCESS WITH SCHOOL AND THE UBMS PROGRAM AND I WILL FULLY SUPPORT MY CHIID’S PARTICIPATION IN THE UBMS PROGRAM. __________________________________________________________ ______________________________ Parent/Guardian Signature Date

PART 8: RECORDS RELEASE

I authorize the Upward Bound Math and Science Program at Indian River State College to access and/or request copies of academic transcripts, grade reports, report cards, standardized test scores, contact information, and any other academic information from the high schools and colleges I attend through my college graduation. Print Student Name: ____________________________________________________________ ______________________________________________________ _______________________________________ Student Signature Date

I/We also give permission to Indian River State College’s Upward Bound Math and Science Program to request the information identified above from each high school and college that our son or daughter attends: ________________________________________________ Print Parent/Guardian Name

_____________________________________________________ _____________________________________

Parent/Guardian Signature Date

PHOTO AND PRESS RELEASE

I, being the parent or guardian of _______________________________, hereby consent that the photographs and/or motion picture film for

which (s)he posed, and/or audio recordings made of his/her voice may be used by Indian River State College and the Indian River State College

Upward Bound Math & Science Program, its assigns or successors, in whatever way they desire, including television; furthermore, I hereby

consent that such photographs, films, and recordings, and the plates and/or tapes from which they are made shall be Indian River State College

and the Indian River State College Upward Bound Math & Science Program property, and they shall have the right to sell, duplicate, reproduce

and make other uses of such photographs, films, recordings, plates and tapes as they may desire free and clear of any claim whatsoever on my

part.

_________________________________ Parent(s) or Guardian(s) Signature:

This program is offered through a federal grant of $250,000 for fiscal year 2010-11 from the U.S. Department of Education, with facilities and administrative support provided by Indian River State College

Indian River State College and the Upward Bound Math & Science program does not discriminate on the basis of race, color, national origin, sex, disability, ethnicity, marital status, or age in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Dean Adriene Jefferson Dover, Equity Officer, IRSC Main Campus, 772-462-7644.

Upward Bound Math and Science Program MATH TEACHER RECOMMENDATION FORM

To the student: This form needs to be completed by a TEACHER OR COUNSELOR.

To the teacher/counselor: The Upward Bound Math and Science are designed to prepare and motivate students with academic potential for

success in postsecondary education. Your evaluation of the student is extremely beneficial to us in determining if the student will succeed in this

highly intensive program. Please rate the student on each of the following areas of personal competence. If you would like to add additional

comments or special considerations on why this student should be accepted, please feel free to continue on the back. Thank you!

Student Name:____________________________________________________ School: ___________________________ Teacher Name:__________________________ Phone:__________________________ Date:____________________ Teacher’s Signature: _____________________________________________________________________________________

Based on your interactions and observations, please circle the number that best describes this student. Please respond

to ALL questions. Very High High Avg Low

Demonstrated interest in math and/or science 4 3 2 1

Level of motivation to succeed academically 4 3 2 1

Perseverance in completing tasks 4 3 2 1

Willingness to follow directions 4 3 2 1

Demonstration of appropriate classroom behavior 4 3 2 1

Number of unexcused class absences 4 3 2 1

Overall positive attitude about academics 4 3 2 1

Academic potential for postsecondary education 4 3 2 1

Likelihood of benefiting academically and

personally from Upward Bound Math and Science

services 4 3 2 1

Likelihood of pursuing postsecondary education

on his/her own 4 3 2 1

Level of opportunity to work with math and

science tools 4 3 2 1

Level of opportunity to meet/work with math

and science professionals, other than teachers 4 3 2 1

Please help us to better assess this student’s ability to complete a math or science postsecondary degree by commenting freely upon his or her strengths, abilities, special talents or needs in the space below. _______________________________________________________________________________________________

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Upward Bound Math and Science, Indian River State College

3209 Virginia Ave, Phone: 772-462-7238 Fax: 772-462-7885

Upward Bound Math and Science Program SCIENCE TEACHER RECOMMENDATION FORM

To the student: This form needs to be completed by a teacher or counselor.

To the teacher/counselor: The Upward Bound Math and Science are designed to prepare and motivate students with academic potential for

success in postsecondary education. Your evaluation of the student is extremely beneficial to us in determining if the student will succeed in this

highly intensive program. Please rate the student on each of the following areas of personal competence. If you would like to add additional

comments or special considerations on why this student should be accepted, please feel free to continue on the back. Thank you!

Student Name:____________________________________________________ School: ___________________________

Teacher Name:__________________________ Phone:__________________________ Date:____________________

Teacher’s Signature: _____________________________________________________________________________________

Based on your interactions and observations, please circle the number that best describes this student. Please respond to ALL questions. Very High High Avg Low

Demonstrated interest in math and/or science 4 3 2 1

Level of motivation to succeed academically 4 3 2 1

Perseverance in completing tasks 4 3 2 1

Willingness to follow directions 4 3 2 1

Demonstration of appropriate classroom behavior 4 3 2 1

Number of unexcused class absences 4 3 2 1

Overall positive attitude about academics 4 3 2 1

Academic potential for postsecondary education 4 3 2 1

Likelihood of benefiting academically and

personally from Upward Bound Math and Science

services 4 3 2 1

Likelihood of pursuing postsecondary education

on his/her own 4 3 2 1

Level of opportunity to work with math and

science tools 4 3 2 1

Level of opportunity to meet/work with math

and science professionals, other than teachers 4 3 2 1

Please help us to better assess this student’s ability to complete a math or science postsecondary degree by commenting freely upon his or her strengths, abilities, special talents or needs in the space below.

_______________________________________________________________________________________________

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Upward Bound Math and Science, Indian River State College

3209 Virginia Ave, Phone: 772-462-7238 Fax: 772-462-7885

Upward Bound Math and Science Program COUNSELOR RECOMMENDATION FORM

___________________________________________________ is___ / is not______ being recommended Name of student to participate in Student’s Name the Indian River State College Upward Bound Program.

Student’s grade point average is ______________________.

Which of the following best describes the student’s current or school academic program? (1) Vocational (3) General (5) Remedial (7) Other

(2) Commercial (4) College (6) Not Decided Preparatory or Not Known

Does this student intend to pursue post-secondary education? yes no

If no, why?

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Please rate the student’s academic ability and motivation.

Poor Below Average Average Above Average

Academic Ability 1 2 3 4

Motivation 1 2 3 4

Parental Support 1 2 3 4

Discipline 1 2 3 4

Attendance 1 2 3 4

To your knowledge, has the student had any social, physical (health), or psychological problems?

yes no

If yes, please explain

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MO. YR Student’s most likely date of graduation from high school ____________ ______________

Counselor’s Signature:__________________________________ Date: ___________________________

High School Telephone Number: ____________________________________

Please attach the student’s TRANSCRIPT.

The student will not be considered until a transcript and income verification has been received.