Fayetteville State University-UBMS

FAYETTEVILLE

STATE UNIVERSITY

Office of College

Access Programs
- Dear Applicant:
  
  The Upward Bound Math and Science (UBMS) Program at Fayetteville State University is a federally funded educational program which prepares high school students for college and careers in the fields of math and science. The UMBS Program at FSU serves Cumberland County students attending the following schools: Douglas Byrd High, Westover High and Southview High School. Students must have completed the 8th grade at the time of admission into the program.
  
  If you are interested in participating in the Upward Bound Math & Science Program, please follow the below instructions in order to complete the application process:
  
  (1) Complete the entire application packet by supplying all of the required information as outlined.
  (2) Submit a copy of parent’s 1040 or 1040A Income Tax Return for the previous year. (Tax return must include parent’s signature).
  (3) Submit a copy of student’s high school transcript or most recent report card and test scores.
  (4) Sign the Release Form so that your school’s guidance department will release your academic records to Upward Bound Math & Science Program.
  (5) Submit two (2) letters of recommendation: One (1) from an academic teacher or community agency and one (1) from your high school counselor or principal.
  (6) Return the completed application to: Upward Bound Math & Science Program, Attn: Fayetteville State University, 1200 Murchison Road, Fayetteville, NC 28301.
  
  Your application cannot be processed without completing all of the requested information. Once your application has been received, you will be notified by mail of your application status. If you have any questions, please contact our office at (910) 672-1677. Thank you for your interest in our Upward Bound Math & Science Program.
  
  Sincerely,
  
  Rangel Moore
  
  Director
  
  Upward Bound Math & Science Program
- Name*
  
  First NameMILast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone #
  (999)999-9999
- Student Cellular Phone #
  (999)999-9999
- Email Address*
  example@example.com
- Student School ID #
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Age
- Sex
  
  MaleFemale
- Current Grade Level
  
  89101112
- Name of Middle/or High School
- Expected High School Month and Graduation year
  MM/YY
- Citizenship
  
  US CitizenPermanent ResidentOther
- Ethnicity: Are you Hispanic/Latino?
  
  YesNo
- Race
  
  Am. Ind./Alaska NativeAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhiteMultiple RacesOther
- Facebook
- Twitter
- NEEDS ASSESSMENT
- 1. I would like to attend college after graduating from high school.
  
  YesNo
- 2. I would like to participate in classes that will prepare me for the SAT and/or ACT.
  
  YesNo
- 3. I would like to attend college fairs to speak to various college representatives.
  
  YesNo
- 4. I would like to attend college visits in state and out of state.
  
  YesNo
- 5. I would like to develop stronger study skills/test taking skills.
  
  YesNo
- 6. I would like academic assistance in Math, Science, and English and/or Foreign Languages.
  
  YesNo
- 7. I would like assistance with preparing for the End of Course (EOC) exams.
  
  YesNo
- 8. I would like to explore careers in the STEM (Science, Technology, Engineering and Math) fields.
  
  YesNo
- 9. I would like to learn about a more rigorous course load that should be taken to prepare for college.
  
  YesNo
- 10. I would like to learn more about college admissions requirements and online college tools.
  
  YesNo
- 11. I would like to learn about college characteristics regarding college selection.
  
  YesNo
- 12. I would like to learn more about financial economic literacy, financial aid and scholarships.
  
  YesNo
- 13. I have an interest in pursuing a career in the STEM (Science, Technology, Engineering and Math) field.
  
  YesNo
- 14. McKinney Vento Act: I am currently sharing housing due to economic hardships or loss of housing, awaiting foster care placement, living in a foster home, residing in a group home or an emergency /transitional shelter.
  
  YesNo
- 15. I am a military dependent.
  
  YesNo
- 16. I am currently enrolled in the Educational Talent Search Program, Upward Bound Classic, or Boys & Girls Club/Find-A-Friend Program.
  
  YesNo
- Student's Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- This information is needed to certify eligibility for the Program.
  
  ALL INFORMATION ON THIS FORM WILL BE HELD STRICTLY CONFIDENTIAL.
  
  Mother
- Please select one
  
  ParentGuardian
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone
  (999)999-9999
- Work Phone
  (999)999-9999
- Cell Phone
  (999)999-9999
- Email Address
  example@example.com
- Facebook
- Twitter
- Highest Grade Completed
  
  High SchoolSome CollegeBachelor's Degree
- Father
- Please select one
  
  ParentGuardian
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone
  (999)999-9999
- Work Phone
  (999)999-9999
- Cell Phone
  (999)999-9999
- Email Address
  example@example.com
- Facebook
- Twitter
- Highest Grade Completed
  
  High SchoolSome CollegeBachelor's Degree
- Medical History
- Does your child have a physical impairment, medical condition, emotional or psychological problems, or Disability?
  
  YesNo
- If yes, please list
- Does your child take any type of medication?
  
  YesNo
- If yes, please list
- Does your child have any allergies?
  
  YesNo
- If yes, please list
- Income Verification
  
  A copy of your Tax Forms are not required but please complete the questions below from your most recent tax return.
- Did you file income taxes this year?
  
  YesNo
- Family Income
- What is your family's Taxable Income for last year?
  $_____________________
- PLEASE DO NOT USE YOUR ANNUAL SALARY.
  
  *Taxable Income: This information is located on your competed tax forms (1040-line43; 1040A-line 27; 1040EZ-Line 6)
- Do you receive Public Assistance (TANF, SNAP, Social Security, or Disability)?
  
  YesNo
- How many people reside in your household?
- My signature certifies that the above information is correct to the best of my knowledge. I understand that this information is confidential and will only be used for income verification for the program at Fayetteville State University.
- Signature of Parent/Guardian
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Student's Name
  
  First NameMiddle NameLast Name
- Please write an essay as to why you should be selected for the Upward Bound Math & Science Programs at Fayetteville State University. In this essay include what the Upward Bound program can do for you, and what contributions you can make to this program.
- Please provide a short description of yourself including your academic interests and your educational and career goals.
- Student's Name
  
  First NameLast Name
- School
- Student ID # at School
- The information requested on this form will be utilized to assist us in providing services for your child. To provide the most effective services, we may need to obtain information from several sources such as your child’s school of enrollment, testing agencies, counselors, social workers, etc. ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT.
  
  SCHOOL RECORDS
  
  As the parent and/or guardian of {studentsName97}, I grant Upward Bound Math & Science permission to obtain school records, and test results from the secondary school my child is attending. I will also permit Upward Bound Math & Science staff to speak with teachers, counselors, and other school administrators at my child’s school in order to obtain and exchange information as part of the services my child will receive from the Upward Bound Math & Science Program. I authorize the Upward Bound Math & Science Program to access or release copies of my child’s progress reports and/or test scores that are necessary to assist my son/daughter in achieving his/her educational goals.
  
  WAIVER OF LIABILITY
  
  As parent and legal guardian of the above-mentioned student, I authorize and permit my child to participate in field trips, activities, and events offered by the Upward Bound Math & Science Program. I understand that my child may be leaving his/her school campus or Fayetteville State University and may be transported by the Upward Bound Math & Science staff at Fayetteville State University. I agree that Fayetteville State University, the Upward Bound Math & Science Program, the Cumberland County School System, nor the school my child is attending, and anyone associated with Fayetteville State University will not be held liable for any loss, injury, or death related to any field trips, or events. Further, I agree to hold Fayetteville State University, Upward Bound Math & Science, Advisory Committee members, officers, staff, volunteers, the Cumberland County School System, and the school my child is attending harmless from any claims whatsoever occasioned in any of the situations that I have agreed, that Upward Bound Math & Science at Fayetteville State University shall not be held liable.
  
  In the event that my child, {studentsName97} is involved in a medical emergency, I authorize the Upward Bound Math & Science staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc.) if they are unable to contact me for verbal authorization.
- Insurance Name and Number
- Medicaid Card Number
- Emergency Contacts
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Phone Number
  (999)999-9999
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Phone Number
  (999)999-9999
- Media Release
  
  Periodically, students participating in Upward Bound Math & Science Program events may be photographed, filmed, or interviewed. As the parent and/or legal guardian of {studentsName97}, I grant permission for my child to participate in photographs, films, social media or interviews as they pertain to the Upward Bound Math & Science Program and I understand that such pictures, films, social media, or interviews may be used to promote or publicize the Upward Bound Math & Science events or demonstrate how federal funds are being used to assist students.
- Parent's Signature
  
  Clear
- Student's Signature
  
  Clear