Northwest Tri-County Intermediate-UBMS-Application Form

UBMS PROGRAM APPLICATON

Northwest Tri-County Intermediate Unit No. 5

Erie High School, Room A200

3325 Cherry St, Erie, PA 16508

Phone: 814-373-9489

trio@iu5.org

Part 2: School / Academic Information
Current Grade in School*

9th10th11th12th
Most Recent Math Course*
Name of High School*
Name of your High School Counselor

First NameLast Name
If you have ever been enrolled in Upward Bound, Talent Search, GO College or any other program that provides specialized educational programs / services, please complete the following:
Name of Program
Name of Advisor

First NameLast Name

Part 4: Academic / Career Interests
TO BE COMPLETED BY THE STUDENT

PLEASE TAKE TIME TO THINK ABOUT YOUR WRITTEN RESPONSES TO THE QUESTIONS BELOW BEFORE WRITING YOUR ANSWERS. THE BEST ANSWERS WILL BE THOUGHTFUL, STATED IN YOUR OWN WORDS, AND CLEARLY WRITTEN.
1.) Which UBMS services do you believe will be most valuable to you? See Program Information in Part 7. (ex. Career exploration, academic support, study skills, Tutor.com, college prep, STEM exploration activities, Science Saturdays, Summer Institute).*
2.) Identify TWO math or science related careers in which you could see yourself employed. Explain why you are interested in them. *
3.) Explain why you believe that you have the potential to successfully complete a math / science degree in college. Share as many specifics about yourself as you can.*
4.) After graduating from high school I plan to*

Attend collegeGo into the Armed ServicesFind a job and workUndecidedOther

5.) Check the appropriate number below to indicate your interest in math, science, and technology. *

	1 (Not Interested)	2	3	4 (Interested)	5	6	7 (Very Interested)
Math
Science
Computers

6.) Have you applied to participate in any other summer programs, camps or opportunities? Please list them below.

Part 5: Financial Information
THE UPWARD BOUND MATH AND SCIENCE PROGRAM IS A FEDERALLY FUNDED PROGRAM.
FOR THE APPLICANT TO QUALIFY, VERIFICATION OF INCOME IS NECESSARY.
ALL INFORMATION IS CONFIDENTIAL AND FOR PROGRAM USE ONLY.
IF YOU FILE A TAX RETURN: What was your family's total annual TAXABLE INCOME for last year?
Refer to IRS 1040 Line 43; 1040A line 27; or 1040EZ line 6
What was the total number of exemptions claimed on your tax return (filers plus dependents)?
Box 6D
Please provide a copy of your 2023 income tax form with this application.

Browse Files

Cancelof
IF YOU DO NOT FILE A TAX RETURN:

Identify the source and annual amount of each nontaxable income.

What is parent's source of income?

	Dollar Amount
Employment
Unemployment
TANF
Disability
SSI
General Assistance
Child Support
Social Security

FOR YOUR INFORMATION

Size of Family	Income	Size of Family	Income
1	Less Than $22,590	5	Less Than $54,870
2	Less Than $30,660	6	Less Than $62,940
3	Less Than $38,730	7	Less Than $71,010
4	Less Than $46,800	8	Less Than $79,080

For families with more than 8 members, add the following for each additional family member: $8,070

PROGRAM ELIGIBLITY IS DETERMINED BY A COMBINATION OF FINANCIAL AND / OR FIRST GENERATION COLLEGE CRITERIA [PARENT(S) WHO DID NOT RECEIVE FOUR YEAR COLLEGE DEGREES]

Part 6: Parent Commitment / Records Release
I certify that the family and financial information is true, correct and complete to the best of my knowledge. I hereby authorize the Northwest Tri-County Intermediate Unit Upward Bound Math and Science Program to:
- Have access to any of my son’s / daughter’s school or agency records to determine eligibility for the program and to monitor the status and progress in middle, secondary, and post-secondary education and eligibility for financial aid.
- Have access to any of my son’s / daughter’s school health records when a medical condition has been disclosed.
Use my son’s / daughter’s name and/or picture in any newsletter, Web pages, brochures, videos, CDs / DVDs, or other public relations materials that pertain to the Upward Bound Math and Science Program.*

YES, Okay to UseNO, Do Not Use
- Provide in-school academic support services and career exploration in order to assist and encourage my son / daughter with choices regarding education beyond high school.
We understand that the student will be required to attend the six (6) week summer program at Penn State Behrend, Erie PA, and six (6) Science Saturdays each year until his / her graduation from high school.

To add your signature, sign using your mouse or finger on a touch screen.
Parent's/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Part 7: Program Information
Dear Applicant:

If you are currently in ninth through twelfth grade and interested in a career in the fields of math or science, the Northwest Tri-County Intermediate Unit Upward Bound Math and Science Program (IU5/UBMS) may be for you. To qualify, eligible students must meet federal low-income guidelines and / or live with parents / guardians who have not received a four-year college degree, and be enrolled in Erie High School.

Some of the services offered by the Upward Bound Math and Science Program include:
- Career exploration - especially those in science and math fields
- Four (4) Science Saturdays - trips to great locations for science activities with other students from our region
- Six week Summer Academic Institute - robotics, forensics, computer, scientific research - Penn State Behrend (weekends off)
- Exciting science and math exploration activities.
- Study skills, academic support, and college prep help
- Tutor.com - improve and/or advance current math, science and other subjects
- Academic incentives (cash!) for participation in Science Saturdays, Summer Academic Institute, and designated activities
It is important that you understand participation in the Upward Bound Math and Science Program requires that you:

(1) Attend the six (6) - week residential summer session on the campus of Penn State Behrend, Erie, PA, and

(2) Participate in all UBMS activities; Science Saturdays, assignments, and services provided during the school year.

By submitting this application, you are indicating that you are aware of and agree to these commitments, if selected.

We are very pleased that you are interested in UBMS. Please complete ALL questions and sign this Application to be considered for the program. Additional Math and Science Recommendation forms may be sent to complete the approval process. Deadline for the 2024-25 Program Applications is January 16, 2025; however, applications will be considered in the order they are received so you will want to complete yours as soon as possible.

YOUR APPLICATION MUST INCLUDE THE FOLLOWING TO BE COMPLETE:
- Two Recommendation Forms - one from your math instructor and one from your science instructor.
- This Application Form - completely filled out and signed where appropriate.
Thank you for taking the time to complete this application thoroughly. You will be notified regarding your status.

For additional information contact:

Upward Bound Math and Science Program

Northwest Tri-County Intermediate Unit No.5

Erie High School

3325 Cherry St., Room A200

Erie, PA 16508

(814) 373-9489

trio@iu5.org

This program is free for the student and his or her family. Participation in the Upward Bound Math and Science Program does not obligate the student to Penn State Behrend in any way.

The Northwest Tri-County Intermediate Unit No. 5 is an Equal Rights and Opportunities Employer