I, the undersigned, declare under penalty of perjury that all the income reported on this application is true, complete, and accurate to the best of my knowledge.

This information is protected by the Privacy Act. No one may see the information unless they work with, or for the Upward Bound Math & Science Program, or are specifically authorized to see it.

Notification of Social Security Number Collection and Usage

Indian River State College is in compliance with FL Statute 119.071(5) regarding the collection and usage of Social Security numbers. Copies of the IRSC Notification of Social Security Number Collection and Usage document can be obtained from Student Services at all IRSC campuses and at the IRSC website at www.irsc.edu.

GED® 's a registered trademark of the American Council on Education (ACE) and administered exclusively by GED Testing Service LLC under license. This material is not endorsed or approved by ACE or GED Testing Service.

Dear Parent or Guardian:

The IRSC Health and Wellness Center provides student health care services under the supervision of a registered nurse. It is necessary for you to sign this form for your child to receive student health care if he/she is under the age of 18. Your signature below authorizes the appropriate treatment for your child, which may include:

1. First Aid Care
2. Treatment of health problems (stomachaches, earaches, headaches, cuts, sores, colds, coughs, ringworms, etc.)
3. Minor Emergency Care

Your signature on the line below indicates your consent for treatment

Sign below if you do not want the health team to provide any services to your child

If you have any questions, contact the IRSC Health and Wellness Center at (772) 462-7825

RECORDS RELEASE

I authorize the release of school records for the applicant's file that may be requested by the Upward Bound Math & Science program at Indian River State College. I understand that the U.S. Department of Education funds the Upward Bound Math & Science program and will use these records to provide academic advising and other services. I also understand that these records will be handled in a confidential manner and that they will be made available only to program staff and representatives from Federal and State Departments of Education.

This authorization release includes, but is not limited to, the following records:

• Official School Transcript
• Basic Skills Test Results
• Student History File with test scores
• Attendance Record for 8th -12th grades
• Academic History with test scores
• Student grades/progress reports
• Information concerning disciplinary actions
• Test Results (PSAT, SAT, ACT, TABE, P.E.R.T., FSA if available)

Note: A photocopy of this record release form should be accepted as an original and the date of the application has no bearing when the Indian River State College the Upward Bound Math & Science program requests the information.

MEDICAL AUTHORIZATION

If medical services are needed by my son/daughter while participating in the Upward Bound Math & Science program or on field trips, I give my permission for my son/daughter to receive any medical services deemed necessary.

ACTIVITY AND FIELD TRIP AUTHORIZATION/RELEASE

As the parent/guardian of the applicant, I do willingly execute this release in consideration of the educational benefit to be derived by my child in participating in the Upward Bound Math & Science program, a College sponsored activity. I hereby release from liability and hold the College harmless from any and all claims and causes of action which might be brought by my child for loss of property, personal injury or death sustained by my child arising out of travel or activity conducted by or under the control of the College. I understand that the term "College" as used herein shall include the employees, administrators, agents, and Board of Trustees of the College.

PHOTO RELEASE

I hereby grant the Indian River State College Upward Bound Math & Science permission to photograph/video my son/daughter and/or to use their likeness in photograph(s)/video in any and all of its program publications and in any and all other media, whether now known or hereafter existing, controlled by the Indian River State College Upward Bound Math & Science program, in perpetuity, and for other uses by the College or Program. I will make no monetary or other claim against the Indian River State College Upward Bound Math & Science program for the use of the photograph(s)/video.

By signing, I hereby acknowledge and certify that the information contained in this application, and any attached supporting documentation provided, is true and correct.

Return to:
UPWARD BOUND MATH & SCIENCE PROGRAM
INDIAN RIVER STATE COLLEGE
3209 Virginia Avenue
Building E, Room 215
Fort Pierce, Florida 34981-5596

Indian River State College does not discriminate on the basis of race, color, national origin, ethnicity, sex, religion, age, disability, sexual orientation, marital status, veteran status or-genetic information in its programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies:
Adriene B. Jefferson
Equity Officer and Title IX Coordinator
IRSC Main Campus • 3209 Virginia Ave. • Fort Pierce, FL 34981
(772) 462-7156

INDIAN RIVER STATE COLLEGE
UPWARD BOUND MATH & SCIENCE
3209 Virginia Avenue - Building E • Fort Pierce, FL 34981-5596
Telephone: (772) 462-7237

Upward Bound Math & Science (UBMS) is a federally-funded program housed at Indian River State College. In 1990, the Department created UBMS to address the needs for specific instruction in the field of math and science. UBMS provides 67 students in grades 9-12 with academic advising, tutoring, career exploration, financial aid/scholarship and college admissions assistance, college tours and cultural events, and helps them in making appropriate decisions regarding post-secondary school or training.

The ultimate goal of the UBMS program is to assure that participants graduate from high school, apply for and enter the college of their choice, secure financial aid/scholarships to pay for their college education, and graduate with a postsecondary educational credential.

ALL SERVICES PROVIDED ARE FREE OF CHARGE TO PARTICIPANTS !

FREQUENTLY ASKED QUESTIONS

Q: Why do you need a copy of my income taxes?
A: Since services are provided FREE of charge to students, UBMS must verify your family's income using the Department of Education guidelines. For UBMS to determine eligibility for participation, federal regulations require documentation on the applicant's family size, number of exemptions, and taxable income for the preceding calendar year. ALL information is kept confidential and secure within our office.

Q: Do I have to be interested in only math & science in order to join UBMS?
A: No. UBMS provides numerous services to students that include all subjects. The program aims to provide specific instructions in math and science to enhance student interest in Science Technology Engineering and Math (STEM).

Q: Why do you need my child's social security card?
A: To show proof of U.S. citizenship. If your child is not a U.S. citizen, provide a copy of the student's and parent's permanent resident cards.

Q: Do I have to recertify or complete an application every year?
A: No. Once your student has provided all documentation and has been accepted, UBMS automatically enrolls him/her for the following year and works with him/her through high school graduation.

APPLICATION CHECKLIST

To eliminate delay in processing your application, be sure the following is completed:

• Page 4 of the application is signed by the student/applicant and parent/guardian
• Attach copies of the following documents:
  • Student's most recent report card
  • Student's social security card or parent's and student's permanent resident cards
  • Parent/Guardian's most recent 1040/1040A tax return (See example on back). Submit the "Dependent Page" and the "Taxable Income Page". The tax return must be signed by the Parent/Guardian on the second page.
  • Complete all three (3) letters of recommendation.

WHY YOU WANT TO BE AN UPWARD BOUND MATH AND SCIENCE STUDENT

PLEASE NOTE: IF YOU ARE APPLYING, YOU WILL NEED TO COMPLETE THE LIST OF QUESTIONS BELOW. YOUR ANSWERS WILL NEED TO BE A MINIMUM OF 4 TO 5 SENTENCES. IN ADDITION, WE HOPE TO GAIN A BETTER UNDERSTANDING OF YOUR ACADEMIC AND CAREER INTERESTS. IF YOU NEED ADDITIONAL SPACE, ATTACH ANOTHER PIECE OF PAPER.

This program is offered through a federal grant of $301,913 for fiscal year 2017-2022 from the U.S. Department of Education, with facilities and administrative support provided by Indian River State College. Indian River State College and the Upward Bound Math & Science program does not discriminate on the basis of race, color, national origin, sex, disability, ethnicity, marital status, or age in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Dean Adriene Jefferson Dover, Equity Officer, IRSC Main Campus, 772-462-7644.