North Alabama Center For Educational Excell-UBMS-Application Form

All services are FREE, and all information remains confidential

APPLICATION FOR ADMISSION

The North Alabama Center for Educational Excellence (NACEE) Upward Bound Math/Science (UBMS) Program is a pre-college program designed to assist and motivate students to successfully graduate from high school, prepare for college admission, and to successfully complete their baccalaureate degree. Upward Bound Math/Science is a year-round program that offers academic year workshops such as ACT preparation, cultural activities, college tours, college planning, as well as a host of other programs including individualized tutoring and student counseling. Upward Bound Math/Science also offers a summer enrichment program on the campus of University of Alabama Huntsville (UAH) to prepare students for college life by taking college level classes, as well as experiencing a college life.

I am applying for admission into the Upward Bound Math/Science program.

Eligibility:
- Have completed 8th grade and are currently in 9th, 10th, or 11th grade
- Reside in Huntsville (Madison County), Alabama
- Be either first generation to attend college in their family and meet low-income requirements, as defined by the federal government
- Students who are citizens or permanent residents of the United States
- Students who have at least a 2.5 GPA and need academic support
- Be willing to meet daily, Monday-Thursday, after school for tutoring services
- Students who intend to pursue a college education
- Students who complete the application, personal statement and interview process
- Students must indicate an interest in pursuing a career in one of the S.T.E.M./S.T.E.A.M. fields
Application Requirements:
- Completed and signed application
- Completed personal statement-see question (see below)
- Copy of standardized test scores (GEPA statement)
- Copy of most recent report card
- One letter of recommendation from a teacher or guidance counselor
- Copy of valid photo identification
- Signed copy of applicant’s Social Security card (If you do not have one, please call 800-772-1213 to secure a social security card.)
- Most recent copy of parents' federal income tax return (in a sealed envelope)
- Resident alien documentation (if applicable)
- Completed financial verification form
- Birth certificate
Personal Statement Instructions:
- Question: Why should you be considered for admission into NACEE’s Upward Bound Math/Science Program? How would admission into the program assist you in reaching your goals?
  - Must be typed 12pt, Times New Roman font (No more than 250 words or one page)
  - Please attach activity sheet (i.e. community service activities, honors and awards)

Note: The information contained in this application is for the purpose of determining the applicant’s eligibility for the Upward Bound Program. Information is confidential and will be reviewed only by assigned NACEE staff.
Is the applicant a foster child or ward of the court?*

YesNo
A foster child or ward of the court is considered a “family of one” and the child’s support payment is considered that family’s income.
How many persons live in your household, including yourself?*

Does your family receive assistance from any of the following sources?*

Rows	Yes	No
Reduced or Free Lunch
Aid to Families with Dependent Children (AFDC)
Local or Community Welfare
Social Security Benefits
Veteran’s Benefits
Unemployment Compensation
SNAP
Disability Compensation

Please note that Taxable Income is usually lower than Adjustable Gross Income, which is located at the bottom of the first page of most tax forms. Annual Taxable Income can be found on page 2 of most tax return forms. If you have any questions or need assistance locating this information, please contact our office at 256-372-4600.
Family Taxable Income (please check one)*

$0 - $22,590$22,591 - $30,660$30,661 - $38,730$38,731 - $46,800$46,801 - $54,870$54,871 - $62,940$62,941 - $71,010$71,011 - $79,080Other
Please attach signed copies of your parent/guardian’s most recent Federal Income Tax Return (Form 1040EZ, 1040 or 1040A).*

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If your parent/guardian worked but did not file a federal tax return, you would provide copies of their W-2 statements. Payroll stubs are not acceptable. You must provide documentation of nontaxable income (Welfare, Social Security, Unemployment Compensation, etc.) Copies of letters stating the amount of funds to be received, identification cards, completed unemployment forms, and other documents will be accepted as appropriate verification for consideration for admission to the Upward Bound Program.

Certification:

I certify that all information provided in this application is true and accurate to the best of my knowledge.
Parent/Guardian Signature*

Clear
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

PARENT/GUARDIAN INFORMATION:
Student Name*

First NameLast Name
Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*
(999)999-9999
Work Number*
(999)999-9999
PERSON(S) AUTHORIZED WITH WHOM CHILD MAY BE RELEASED:
Name*

First NameLast Name
Relationship*
Name*

First NameLast Name
Relationship*
EMERGENCY CONTACT WHEN A PARENT/GUARDIAN CANNOT BE REACHED:
Name*

First NameLast Name
Cell Number*
(999)999-9999
Work Number*
(999)999-9999
Relationship to Child*
MEDICAL INFORMATION:
Family Physician*
Phone Number*
(999)999-9999
Medications*
Dosage/Time to Take*
Physical Disabilities, etc.*
Allergies*
Date of most recent Tetanus shot*

MonthDayYear
mm-dd-yyyy
Insurance Company*
Policy Number*
We authorize the North Alabama Center for Educational Excellence employees to render any medical care and treatment to our child/ward deemed necessary with respect to any illness or injury occurring during any activities. I (we) understand that the North Alabama Center for Educational Excellence has no medical coverage and I (we) agree to pay additional medical costs incurred.

I understand that NACEE nor its staff are obligated to provide transportation in connection with the Program. I understand that I am expected to carry my own automobile liability insurance coverage if driving on premises or to scheduled events.

Assumption of Risk and Release of Claims: In consideration of being permitted to participate in the Program, I agree, on behalf of my family, heirs, and personal representative(s), to assume all the risks and responsibilities surrounding my participation in the Program. To the maximum extent permitted by law, I release and indemnify NACEE and its staff from and against any present or future claim, loss or liability for injury or injuries to person or property which I may suffer, or for which I may be liable to any other person, during my participation in the Program (including periods in transit).

I have carefully read this Release form before signing it. No representations, statements, or inducements, oral or written, apart from the foregoing written
statement, have been made. This agreement shall become effective only upon receipt by the North Alabama Center for Educational Excellence at its
offices in Alabama and shall be governed by the laws of the state of Alabama.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Witness Signature*

Clear
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Witness Signature*

Clear

I understand that as part of the Upward Bound Math/Science Program selection process, my child’s school records including transcripts, test scores, and academic progress reports may need to be examined. I hereby give permission for the release of all academic information pertaining to my son/daughter to the Upward Bound Math/Science Program including, but not limited to, the following information from my child’s high school and future colleges that he/she may attend:
1. School records
2. Transcripts
3. Standardized test scores
4. Information on the student’s status and performance
5. Student’s contact information
6. Warning/Failure notices
7. Registration forms
8. Academic awards
I understand that if my child is selected for the Upward Bound Math/Science Program, the Upward Bound Math/Science Program will continue to require this information from his/her high school and college. The purpose for collecting this information is to track and evaluate the academic performance of the Programs’ participants and graduates for the entire period of time he/she is enrolled in the Upward Bound Math/Science Program. This consent expires when the participant no longer receives program services and/or the Upward Bound Math/Science Program is no longer federally mandated to track the participant/graduate’s academic performance.
High School*
Print Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Print Student Name*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

I, {printParentguardian117} , hereby give permission for the release of all of my academic
information to the Upward Bound Math/Science Program including, but not limited to, the following:
1. School records
2. Transcripts
3. Information on the student’s status and performance
4. Student’s contact information
5. Warning/failure notices
6. Registration forms
7. Academic awards
I understand that the Upward Bound Math/Science Program will continue to require this information in order to track and evaluate the academic performance of the Programs’ participants/graduates until the Upward Bound Math/Science Program is no longer federally mandated to track the participant/graduate’s academic performance. I have been provided a copy of this form.
Print Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Social Security/Student ID Number*
Print Student Name*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

As the parent/guardian of the applicant, I declare that all information provided in this document is correct and true to the best of my knowledge. My signature certifies that the attached information is correct and that any false or misleading information may result in disqualification of the applicant. I further understand that this information being provided is for the receipt of federal funds.

I hereby authorize the Upward Bound Math/Science Program to release and receive data regarding my son/daughter to assist my son/daughter with his/her educational planning. My child plans to complete high school and attend a program of postsecondary education, and will need the services of the Upward Bound Math/Science Program. I hereby grant permission to the personnel of my child's school to release copies of transcripts, test scores, and academic progress reports to the Upward Bound Math/Science staff.

I understand that if accepted into the Upward Bound Math/Science Program, I must apply for, and if accepted, attend the following mandatory dates:

Twice Monthly Saturday Sessions	September 2022 – May 2023
Anticipated NACEE Summer Component	June 2023 – July 2023

Applicant Name*

First NameLast Name
Applicant Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

The Upward Bound Math/Science Program makes every effort to promote the positive activities, honors, and work of our staff and students. This includes working with the local newspapers, radio, and television stations and also developing our own publications. These publications include information, likenesses, and images, which may appear in the local media as well as in other publications.

As we go about this project, there will be opportunities for various students to be interviewed and/or photographed and identified by name and grade or school. However, we understand that some parents may request that we do not identify their child(ren). Please fill out the form below to inform us of your wishes regarding publicity. Please note, your child’s image or likeness may appear in occasional candid photos without any type of name identification and the use of these candid photos of your child is permissible.

I, {parentguardianName136} , give NACEE permission to record the image and/or voice of the minor named below, and I grant NACEE all rights to use these sounds, still, or moving images in any medium for educational, promotional, advertising, or other purposes that support the mission of the Upward Bound Math/Science program. I agree that all rights to the sound, still, or moving images belong to the Upward Bound Math/Science Program.
Student Name*

First NameLast Name
Grade*
Parent/Guardian Name*

First NameLast Name
Photograph & Video Consent*

I give permission for my child to be interviewed, identified, and/or photographed/filmed for use in program publications, including, but not limited to, publication via web site or other technological publications, videos, newspapers, radio, or television. By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.I request that you do not interview or photograph my child.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Student Name*

First NameLast Name
Intended High School Name*
Grade*
Primary Telephone Number*
(999)999-9999
Uniform Requirement (See Dress Code Policy in manual)

As detailed in the 2018 Summer Manual, students will be required to adhere to a uniform dress code. NACEE Upward Bound Math/Science program will provide one t-shirt at no cost to you.
Please indicate size below*

XSmallSmallMediumLargeXLargeXXLargeXXXLargeOther
Email Requirement

All students & parent/legal guardians must obtain Google email accounts “Gmail” for direct line of communication between the program participants and their families.

It is mandatory that an account is created. You may use an existing gmail account, but it is preferred for you to include your name within the email address. Additionally, please provide one alternate email address that you check regularly.
Student Gmail Account*
example@example.com
Student Alternate Account*
example@example.com
Parent Gmail Account*
example@example.com
Parent Alternate Account*
example@example.com

Personal Statement
Why should you be considered for admission into NACEE’s Jackson County Upward Bound Program? How would admission into the program assist you in reaching your goals? (Must be typed 12pt, Times New Roman font (No more than 250 words or one page)

0/250
Activity Sheet Upload

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