UBMS New Student Application

Part I: Student Information

High School currently attending/Will attend: *

Is student in any of these programs?

First Name *

Middle Name

Last Name *

Email *

Address *

City *

State *

Zip *

Phone *

Student's Citizenship Status *

Gender *

Date of Birth *

Grade Level *

Current Grade Point Average (GPA) *

School ID Number *

Counselor Name *

Ethnicity *

Other Ethnicity (Please Specify)

ALL INFORMATION PROVIDED IS CONFIDENTIAL AND WILL NOT BE SHARED WITHOUT PARENTAL CONSENT

Part II: Parent/Guardian Information

Mother/Guardian 1 Name *

Mother/Guardian 1 Relationship *

Mother/Guardian 1 Phone *

Mother/Guardian 1 Email Address *

Mother/Guardian 1 address is: *

If different please provide:

Mother/Guardian 1 Degree *

Father/Guardian 2 Name

Father/Guardian 2 Relationship

Father/Guardian 2 Phone

Father/Guardian 2 Email Address

Father/Guardian 2 Address is:

If different please provide:

Father/Guardian 2 Degree

Part III: Family Income Information

Taxable Income (1040 Tax Form Line #15) *

How many people are living in your household? *

Does student participate in free / reduced lunch? *

Part IV: College & Career

What is your planned college major? *

What are your career interests? *

Please explain why you would like to attend the Upward Bound Math-Science program at Pasadena City College. In which areas (academic or personal) can our program help you improve? (at least 2 sentences)

*

Describe a math or science related problem in the world, why is it an issue, and why is it important to you? (at least 4 sentences)

*

Why is it important for you to attend college? Is this a goal for yourself or your family? (at least 3 sentences)

*

Upward Bound Math-Science scholars benefit most from our program through participation. We offer tutoring, college and career workshops, STEM Academies, Educational Advising, fieldtrips, and summer programming to mention a few. Please share with us your commitment to staying staying engaged. (at least 2 sentences)

*

Please list meaningful activities you would like to be a part of in each category:

Career Exploration *

Academic Preparation *

Personal Development *

Please list the school, community, sports, and other activities you are involved in:

Part V: Parent/Student Contract

1. I understand that priority will be given to students who meet both the federal low-income guidelines and that neither parent graduated from college.

2. If selected as a participant of the Upward Bound Math-Science program at Pasadena City College, I agree to participate in the entire program, including the tutorial sessions, the Saturday Academies, and 5-week summer program. Arrangements may be made ahead of time with the Director or Educational Advisor.

3. If accepted, I will conduct myself in a manner that will bring credit to my family, my school, my community, and myself. I also agree to abide by the rules and regulations established by the Upward Bound Math-Science Program during all program activities.

4. If selected as a participant of Upward Bound Math-Science I will work towards attending a 2-year or 4-year college following high school.

5. I understand that the Director has the right to dismiss a student if the student does not adhere to the rules of the program or is not showing participating in the activities of the program.

By initialing here I (student) acknowledge sections 1-5 above. *

Part VI Continued: Parent/Guardian:

By signing below I (Parent / Guardian) certify that the information provided in this application is accurate. I understand that the Upward Bound Math-Science Program may deny my child's admission if any information is found to be incomplete or inaccurate.

I (Parent / Guardian) hereby authorize the Upward Bound Math-Science program at Pasadena City College to obtain transcripts and other academic cumulative records for the above named student. Information may contain high school graduation requirements: credits completed; Grade Point Average (GPA); college admission and other test scores such as SBAC, SAT and ACT; and other information necessary to provide services. I understand that I will be asked to make my social security card available upon request.

Today's date *

Parent/Guardian Signature (Select Text or Email, enter the code, and sign)

Please select a signature verification type.

Student Signature (Select Text or Email, enter the code, and sign)

Please select a signature verification type.

Signature from parents/guardian and student is required. Click here if you prefer to sign at a later time.