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 

NEEDS ASSESSMENT

This information is needed to certify eligibility for the Program.

ALL INFORMATION ON THIS FORM WILL BE HELD STRICTLY CONFIDENTIAL.

 

Mother 

Father

Medical History 

Income Verification

A copy of your Tax Forms are not required but please complete the questions below from your most recent tax return.

Family Income 

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)

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.

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.

Emergency Contacts 

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.