Southern University-New Orleans-UBMS

Southern University at New Orleans
UPWARD BOUND MATH & SCIENCE TRIO PROGRAM

6801 Press Drive
New Orleans, Louisiana 70126
(504) 286-5249 Office
(504) 284-5487 Fax

ubms@my.suno.edu

Part II. Academic Information
Please upload your academic records*

Browse Files

Cancelof
Please upload your test scores*

Browse Files

Cancelof
Name of High School
Grade Level

89101112
Current Overall Cumulative Grade Point Average (GPA)
Do you participate in your school's free lunch program?

YesNo
School Counselor/Advisor
Date of Expected Graduation

MonthDayYear
mm-dd-yyyy
Are you currently a participant in an Upward Bound, Talent Search or Gear Up Program?

YN

Part IV. Parent Information
(To be completed by the parent or guardian)

Federal regulations require documentation of family income and educational attainment of parent(s)/Guradian(s) to determine student eligibility to participate in Upward Bound Math & Science Program. We cannot accept applications without proof of income. The information you give us will be kept confidential and is protected by the Federal Privacy Act, HIPA Act, FERPA and COPPA.
Who does the student currently live with?

MotherFatherBothGuardianOther
Parent/Guardian Name

First NameMiddle InitialLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone Number
(999)999-9999
Cell Phone Number
(999)999-9999
Email Address
example@example.com
Mother: Have you graduated from a 4-year college or university?

YesNo
Father: Have you graduated from a 4-year college or university?

YesNo
Please upload your Parent Income*

Browse Files

Cancelof
Parent/Guardian Yearly Income Status
Self-employment Amount
Social Security Amount
Employment Amount
AFDC/Welfare Amount
Disability Amount
Other
Total number of persons residing/living in household
Adults
Children
Total
As the parent/guardian, I understand that the Upward Bound Math & Science Program must verify eligibility for all of its participants, including family income, educational attainment of parent(s), and family size. With my signature, I certify that all information listed above is correct, true and complete to the best of my knowledge.

Furthermore, in signing this statement, I am the legal guardian for the student listed in Section I and give my permission for the release of information regarding educational records and required documentation for the applicant named in Section I to participate in the Upward Bound Math & Science Program and to track educational progress through the student’s post-secondary education.

S645.4 (i) In compliance with Sec. 402A€ 1070a-11of HEA, I hereby certify that the information I have furnished regarding the size of my family and taxable income is true to the best of my knowledge.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Part V. Authorization for Release of Records and Liability
I hereby consent to the release of my (students’) high school records (report cards, test scores, transcripts, and other information regarding my high school performance) to Southern University at New Orleans Upward Bound Math & Science Program. This release is effective for any high school that I attend during and after participation in Upward Bound Math & Science.
Student Name

First NameLast Name
Student Social Security Number
999-99-9999
Student Date of Birth

MonthDayYear
mm-dd-yyyy
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Part VI. Application and Verification Checklist
Each potential participant must submit a completed application package of the following information and materials to verify eligibility for the Upward Bound Math & Science Program.
- Complete signed and dated application
- Income verification documentation (Tax-1040(a)) (if available)
- Copy of current school schedule
- Copy of high school report card/transcript
- Copy of Standardized Test Scores
- Teacher and Counselor Recommendation Forms
Equal Opportunity Statement

This institute, in compliance with Title VI and VII of the Civil Rights Act of 1972, and the Federal laws and regulations, does not discriminate on basis of race, color, national origin, sex, age, religion, handicap, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to admissions, employment, financial aid and educational services.