UPWARD BOUND MATH AND SCIENCE CENTER - … fil… · my child to be utilized by UBMS-Urban staff...

UPWARD BOUND MATH & SCIENCE URBAN

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Student’s Name:

Students will not be considered for the Math & Science Urban Program if the following

documentation is not provided.

Documentation Check List

1. ____ Provide a copy or your parents current tax records or other proof of income if a

tax return was not filed

2. ____ Provide a copy of your current academic transcript.

3. ____ Provide a list of three references (family relatives).

4. ____ Math teacher recommendation

5. ____ Science teacher recommendation

6. ____ High School Counselor

* Only students with complete applications will be interviewed.

Texas A&M University-Kingsville Upward Bound Math & Science Urban Program

UPWARD BOUND MATH AND SCIENCE URBAN PROGRAM

APPLICATION FORM

SECTION I: To Be Completed By Student

Date: _______________

Name: _______________________________________________ Sex: Male_____ Female______ (Last) (First) (MI)

Mailing Address: _________________________________________________________________ P.O. Box or Street

________________________________________________________________________________ City State Zip

Phone Number: (_____) __________________ Social Security #: ______-______-______

Date of Birth: ______________ Place of Birth: _________________ Age: ____ Grade Level: _____

Are you a U.S. Citizen? __Yes __No

Ethnic Background: Asian __ Black/African American __

(For demographic data only) Native American __ White __

Hispanic __ Pacific Islander __

Other (Specify) ______________

Number in family living at home ____Adults

+____Children

= ____Total

Will you require any special accommodations for any physical or other limitation(s)? __Yes __No

If yes, please explain: ____________________________________________________________

_____________________________________________________________________________

Are you an Upward Bound (UB), Upward Bound Math and Science (UBMS), or Talent Search (TS)

member? (Check One) _____Yes _____No

If so, which university or organization? ____________________________________________

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Name of High School: __________________________________ Current Grade: ___________

Who is your Counselor? ___________________________________________________________

What is your Counselor’s Mailing Address? _________________________________________________________________________________ P.O. Box or Street

______________________________________________________________________________________________________________

City State Zip

Phone #: _________________________ E-mail: _________________________________________

1. In what clubs, activities, or organizations have you participated (music, drama, sports, etc)?

__________________________________________________________________________________________________________

2. Are you currently enrolled in Advanced Diploma or Honors Classes? ___Yes ___No

3. In which course(s) do you need the most help? ______________________________________

4. Have you participated in a school science fair? ___ Yes ___ No

If yes, what was your science fair project? _________________________________________

5. Have you participated in UIL? ____ Yes____ No

If Yes, what events? Math: _____________________________________________

Number Sense: ______________________________________

Science: ___________________________________________

Other: _____________________________________________

6. Your ultimate ambition after high school includes: (Check One) ___ a two year ___ a four year ___ more than four ___ Voc-Tech or ___ no further

College College years of College Trade School schooling after

Degree Degree of an advance degree High School

7. What career or careers are you considering for yourself?

______________________________________________________________________________

______________________________________________________________________________

8. Rank in order of preference, the major field of study in which you would like to concentrate

while at the Upward Bound Math and Science Urban Program (With #1 being most interested).

___Biology ___Computer Science ___Engineering ___Physics

____Biomedical Science ___Chemistry ___Mathematics

9. Would you be interested in (outdoor) field research? Yes No

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Student Essays

Essay # 1

You have been asked into college and you have decided to live in a campus dormitory. The

college has asked you to write a one paragraph letter to your roommate describing yourself, your

interests and your values. Write that letter in the space below. You may wish to write what is

important to you in life and why.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Essay #2 In the space below, state why you wish to participate in the Texas A&M University-Kingsville Upward

Bound Math & Science Urban Program.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________________

Essay #3 Please describe the ways in which you will work to get the most out of this program.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________________


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List the high school courses (if any) that you have taken in the following categories:

General Sciences Final Semester Physics Final Semester

Grade Received Grade Received 1.____________________ ____ 1.____________________ ____

2.____________________ ____ 2.____________________ ____

Biology Final Semester Mathematics Final Semester Grade Received Grade Received

1._____________________ ____ 1._____________________ ____

2._____________________ ____ 2._____________________ ____

3._____________________ ____

Chemistry Final Semester Computer-Based Courses Final Semester Grade Received Grade Received

1.____________________ ____ 1.____________________ ____

2.____________________ ____ 2.____________________ ____

List all computer programs or languages you have used.

1.______________________ 3.________________________ 5.____________________

2.______________________ 4.________________________ 6.____________________

ELIGIBILITY STATEMENT

I hereby acknowledge that I understand the eligibility criteria and expectations for acceptance in the

Upward Bound Math & Science Urban Program at Texas A&M University – Kingsville.

I certify that I meet all eligibility criteria which include: Be officially enrolled in school

Currently attending the 9h and 10th grade

Must be between the ages of 14 and 21

Be a legal resident of the State of Texas

Meet the current poverty guidelines

Provide the three recommendation forms included in this application

1.from your Math Teacher, 2. Science Teacher, and 3. School Counselor

I am currently enrolled in the ___ grade at __________________________ High School

_________________________________________ ________________________ Signature of Applicant Date


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Section II: To be completed by the applicant’s Parents or Guardians

Father or Male Guardian’s Name: ________________________________________________ (Last) (First) (MI)

Home Address: _____________________________________________________________ (No. & Street) (City) (Zip)

Home Phone Number: ( ) _________________ Cell Phone Number: ( )____________

Level of Education: (Please Circle)

a.) Middle/Jr. High b.) H.S. Diploma/GED c.) Associates Degree d.) B.A. Degree or Beyond

Occupation: ___________________________ Place of Employment: __________________

Work Phone Number: _________________

Mother or Female Guardian’s Name: _____________________________________________ (Last) (First) (MI)

Home Address______________________________________________________________ (No. & Street) (City) (Zip)

Home Phone Number: ( ) ________________ Cell Phone Number: ( )_____________

Level of Education: (Please Circle)

b.) Middle/Jr. High b.) H.S. Diploma/GED c.) Associates Degree d.) B.A. Degree or Beyond

Occupation: __________________________ Place Of Employment: ________________

Work Phone Number: ________________

Head of Household’s relationship to applicant: ______________________________________

I hereby grant permission for my son/daughter ___________________________to participate in the

Texas A&M University-Kingsville Upward Bound Math and Science Urban residential summer program.

I also give my consent to the Upward Bound Math and Science Urban Program to obtain high school and

university/college transcripts or any educational records, which pertain to my child’s academic

progress in school. As a parent I will fully support the goals of the program

and help my son/daughter to attain these goals.

_____________________________________________ ___________________ Father’s/Male Guardian’s Signature Date

_____________________________________________ ___________________ Mother’s/Female Guardian’s Signature Date

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Parental Permission to Attend and Participate

Texas A&M University-Kingsville

Upward Bound Math & Science Urban Program

I hereby give permission for my son/daughter, ____________________________, to attend and

participate in the Upward Bound Math & Science Urban Program (including the summer

component, follow-up sessions, project fairs, and field trips) at Texas A&M University-Kingsville.

I understand that he/she will be provided room and board at an on-campus resident hall and that

responsible staff members will be employed by the program and Texas A&M University-Kingsville

to supervise all participant activities.

I also understand that Texas A&M University-Kingsville and Upward Bound Math &

Science Urban Program will provide maximum security and will do everything in its power to

supervise the off-campus planned activities of my son/daughter. However, my son/daughter must

be in compliance with, and abide by, all rules, regulations, and policies established by Texas A&M

University-Kingsville and Upward Bound Math & Science Urban Program. Neither Texas A&M

University-Kingsville nor Upward Bound Math & Science Urban Program will be responsible for

any accident, injury, or other misfortune which occurs as a result of a participant’s violation of rules,

regulations, and policies.

__________________________ __________ __________________________ __________ Parent/Guardian Signature Date Student Signature Date


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Medical Attention Form

Texas A&M University-Kingsville

Upward Bound Math & Science Urban Program

Notice to Parent or Guardian:

Occasionally there is a need for immediate medical attention due to sudden illness or

accidents. As you may know, hospitals will not administer medical care unless they have

parental consent.

Should an emergency or need for medical or psychological attention or testing occur

(Clinic, Dentist, X-RAY), the hospital or clinic must have your consent. Therefore, to assure proper

care for your son/daughter, please fill out this form.

___________________________________ Student’s Name

Statement of Parental Consent

I hereby authorize the Director or designated representative of the program to sign in my place as

needed for medical or dental attention.

__________________________ __________ __________________________ __________ Parent/Guardian Signature Date Student Signature Date


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Reference Information Please list references of three relatives not living in the student’s household. Be sure to include

address and telephone numbers since this information will be used for student tracking and

emergency notification purposes

(1) Name: _______________________________________Relationship to you: ___________________

Address: _____________________________________________________________________________

City, State, Zip: _______________________________________________________________________

Telephone Number: ( ) __________ - __________


Address: _____________________________________________________________________________

City, State, Zip: _______________________________________________________________________



Address: _____________________________________________________________________________

City, State, Zip: _______________________________________________________________________



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Upward Bound Math & Science Urban Program’s Expectations of the Participants

1. To attend all meetings and activities scheduled for the participants.

2. To commit oneself to complete the six-week summer program.

3. To adapt and learn from a university environment.

4. To comply with all university rules and to be a positive representative of the Department of Student

Access and Texas A&M University-Kingsville.

5. To attend all classes and activities on time, unless officially excused.

6. To turn in all assignments on time, including year round.

7. To meet with counselors, mentors, and facilitators when scheduled.

8. To attend P.E. activities.

9. To attend all mandatory weekend trips, and outings, unless officially excused by 3-day prior notice.

10. To keep dorm room and personal belongings neat and orderly and follow resident hall rules at all times.

11. All participants are responsible for personal belongings if lost, stolen, or damaged.

12. To pay for repairs or replacements of any damaged property.

13. To have on file the results of a physical examination administered within the last six months or

upon arrival at Texas A&M University-Kingsville and an updated medical history form.

14. Students are expected to conduct themselves in good taste with regard for others’ feelings and to not

infringe upon the rights of others.

15. Participants are to remain on campus at all times unless accompanied by a staff member or parent.

16. Smoking is not allowed inside the dorms, classrooms, or at any program activity.

17. Program policy prohibits the use or possession of alcohol and/or illegal drugs while enrolled in the

program. Zero Tolerance!

18. The use of prescription drugs is prohibited unless under the medical supervisions of the

University Health Center or a physician.

19. No weapons allowed. Zero Tolerance!

20. Clothing, which depicts, drugs, alcohol, satanic, vulgar, pornographic material, and/or gang- related

activity, will not be allowed.

I have read the Expectations of the Participant and understand that failure to comply with any of these expectations

or conditions stated may result in my termination from the program.

__________________________ __________ __________________________ __________ Student Signature Date Parent/Guardian Signature Date

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UPWARD BOUND MATH & SCIENCE – URBAN

Student Photo Release Form

I hereby grant the absolute right and permission for photographs and/or videotaping of

my child to be utilized by UBMS-Urban staff for publication purposes such as newspapers,

web pages, brochures, etc...

Student Signature: _____________________________________________________

Date: ______________________________________________________________

Parent/Guardian Signature: ______________________________________________

Date: ________________________________________________________________

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What Participants Can Expect From Upward Bound Math & Science Urban Program

1. An Upward Bound Math & Science Urban Program Scholarship to cover the expenses of room and board, books,

and health insurance for the summer.

2. Student facilitator assistance in adjusting to college surroundings and the University system.

3. Academic advisement for the fulfillment or your long-range goals.

4. Assistance in planning for the years ahead to include college and career preferences in the

math and science fields.

5. Counseling and student services.

6. Intensive instruction and laboratory research assistance in the math and science fields.

7. Enrichment seminars and workshops to increase participants’ knowledge of and exposure to

math and science.

8. Recreational events including indoor/outdoor activities.

9. Weekend trips to places of interest.

10. Dormitory facilities will be staffed to supervise and coordinate such facilities.

11. Participants will be assigned rooms in the resident halls according to the rules, regulations, and policies established

by the Upward Bound Math & Science Urban Program and Texas A&M University-Kingsville.

12. Three nutritionally balanced meals per day during the summer component.

13. Health care at the Health Center, local hospitals, and physician’s services will be available

up to the maximum limits of the student insurance paid for by the program.

14. Emergency leave will be granted to participants only upon written consent from parent or

legal guardians.

15. Students will be given assistance in applying for College Financial Aid and the admission’s process

to the College/University of their choice.


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TEXAS A&M UNIVERSITY-KINGSVILLE UPWARD BOUND MATH AND SCIENCE URBAN PROGRAM RECOMMENDATION FORM

COUNSELOR RECOMMENDATION FORM

______________________________________________________________________ _______________________________

Name of Student Current Grade

How long have you known the student? ______________________________________________________________

Please rate the student in the following areas: (Check Appropriate Box)

Please make a personal comment on how this student could benefit from the program.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

_____________________________________________________________________________________________

______ I Strongly Recommend ______Recommend ______Recommend with Reservation

___________________________________________________ _____________________ Name (Print) High School

_________________________________________________________ ________________________

Signature Date

Exceptional

Above

Average

Average

Below

Average

No Basis for

Judgment

Academic Potential

Motivation

Leadership

Attendance

Responsibilities

Relation with Others

Science Skills

Math Skills

Computer Skills

Writing Skills

Overall Conduct


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MATH TEACHER RECOMMENDATION FORM

______________________________________________________________________ _______________________________





______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______ I Strongly Recommend ______Recommend ______Recommend with Reservation


_________________________________________________________ ________________________

Signature Date

Exceptional

Above

Average

Average

Below

Average

No Basis for

Judgment

Academic Potential

Motivation

Leadership

Attendance

Responsibilities


Science Skills

Math Skills

Computer Skills

Writing Skills

Overall Conduct


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SCIENCE TEACHER RECOMMENDATION FORM

______________________________________________________________________ _______________________________





______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

_____ I Strongly Recommend ______Recommend ______Recommend with Reservation


_________________________________________________________ ________________________

Signature Date

Exceptional

Above

Average

Average

Below

Average

No Basis for

Judgment

Academic Potential

Motivation

Leadership

Attendance

Responsibilities


Science Skills

Math Skills

Computer Skills

Writing Skills

Overall Conduct


UPWARD BOUND MATH AND SCIENCE CENTER - … fil… · my child to be utilized by UBMS-Urban staff...

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