Tusculum College-UBMS-Application Form

TUSCULUM UNIVERSITY TRIO PROGRAMS
UPWARD BOUND MATH AND SCIENCE APPLICATION

Part A. To Be Completed by Student
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
(999)999-9999
Student Cell Phone
(999)999-9999
Social Security Number
999-99-9999
Birthdate

MonthDayYear
mm-dd-yyyy
Age
Are you a U.S. Citizen?

YesNo
Sex

MaleFemale
Race (select all that apply)

American IndianAlaskan NativeAsianBlack or African AmericanHispanic or LatinoWhiteNative Hawaiianor other Pacific IslanderOther
Are you physically handicapped?

YesNo
If yes, handicapping condition?
High School
Grade
Name of teacher we can ask for recommendation

First NameLast Name
School of teacher we can ask for recommendation
Are you currently enrolled in Educational Talent Search?

YesNo
Are you currently enrolled in Upward Bound?

YesNo
What was your grade point average at the end of last semester?
Do you want to go to college after you finish high school?

YesNo

List three careers that interest you. (Things you would like to do after you complete college)

	Career Name
1
2
3

Please write a brief paragraph about how Upward Bound Math and Science can help you and why you want to be an Upward Bound Math and Science student.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Part B. To Be Completed by Parent(s) or Guardian

Household Information: (List only the persons with whom you reside)

	Name	Occupation	Employer	Address	Phone (H)	Phone (W)	Cell Phone
Mother
Stepmother
Father
Stepfather
Guardian

INCOME INFORMATION: Upward Bound Math and Science is federally funded. In order to comply with federal regulations, we must collect family income information. Therefore, we request that you attach a copy of the income tax return from the calendar year preceding the one in which your child will participate in the program.
If you DID NOT file income tax last year please indicate this below.

I DID file income tax last year.I DID NOT file income tax last year.
Please attach a copy of your current income tax return form. All information provided will be used to determine the applicant's eligibility for Upward Bound Math and Science. Students will NOT be eligible to participate in Upward Bound Math and Science without submitting the tax form.

Cancelof
Family Taxable Income: The information we need is your family's Taxable Income NOT your total annual income. Taxable Income is smaller than total income. Taxable Income is the amount on your tax return after all adjustments, exemptions and deductions have been subtracted. (Usually line 43 on a 1040).
Family Taxable Income
Number in Household (Include students away at school)
Did the natural or adoptive mother with whom the applicant resides graduate from high school?

YesNo
Did the natural or adoptive father with whom the applicant resides graduate from high school?

YesNo
Does the natural or adoptive mother with whom the applicant resides have a four year college degree?

YesNo
Does the natural or adoptive father with whom the applicant resides have a four year college degree?

YesNo
I certify that the above information and income data is correct to the best of my knowledge; further, I understand that all information provided will be held in strictest confidence.
Signature of Parent or Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Income Verification Form
This form should be used if you did NOT file a federal income tax.
Student Name

First NameLast Name
Parent Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This form is to verify that a Federal Income Tax Form was not filed for {year}
Year
Non-taxable Income received (Please check all types received)

Social SecurityUnemploymentDisabilityAFDCVeterans BenefitsChild SupportOther (please list)
I understand that the above information will be held in the strictest confidence and
used to determine my student's eligibility for participation in the Tusculum University Upward Bound Math and Science program. I also certify that all the above information and income data is complete and correct to the best of my knowledge.
Signature of Parent or Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

School Record Release
Permission is hereby granted to the appropriate office of the high school and/or postsecondary institution attended by {main_name} to issue a transcript/financial aid, and enrollment information for this student to the Upward Bound Math and Science Program, Box 5053, Tusculum University, Greeneville, TN 37743.
Student's Signature

Clear
Student's Social Security Number
999-99-9999
Parent's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Code of Conduct and Honor
At Tusculum University Upward Bound Math and Science, we strive to make our program as safe and rewarding as possible for all of our participants. We expect our students to behave in a manner that reflects the positive reputation of the Upward Bound Math and Science program. With this in mind, the following violations are subject to warning or could result in suspension or dismissal from the phase or program:
1. Failure to comply with the reasonable instructions of any staff person.
2. Interfering with any UBMS staff member while performing program duties.
3. Providing false information to staff members with the intent to deceive.
4. Use or possession of any tobacco product.
5. Verbal abuse of participants or UBMS staff members.
6. Disorderly conduct, including the use of foul language.
7. Misuse of the internet.
8. Bullying, cyberbullying, hazing, sexual harassment, and/or sexual misconduct.
The following violations will result in immediate dismissal from the program:
1. Use or possession of alcoholic beverages, marijuana, dangerous drugs or paraphernalia.
2. Committing violence against any participant, instructor or staff member.
3. Use or possession of firearms, explosives, knives or weapons of any kind.
Tusculum University Upward Bound Math and Science is an opportunity for me to develop my potential for success in college. I fully intend to utilize that opportunity by working with the Upward Bound Math and Science staff to enhance my talents, abilities, and strengths and to improve upon my weaknesses.

I realize that my obligations to Upward Bound Math and Science have been determined and outlined in this contract only for my benefit.
1. I will complete Upward Bound Math and Science through my involvement until the end of the summer following my graduation from high school.
2. I will do my very best in school and in Upward Bound Math and Science courses by maintaining at least a 2.5 GPA.
3. I will obey all program rules and regulations.
4. I will attend activities and tutoring (as needed) during my freshman through senior years.
5. I will meet with my assigned Upward Bound Math and Science counselor.
6. I will attend Upward Bound Math and Science summer phases.
7. I will enroll in college after completion of the Upward Bound Math and Science program and obtain a college degree.
Signatures indicate a commitment to the Upward Bound Math and Science program. I understand that a failure to follow the Tusculum University Upward Bound Math and Science Code of Conduct and Honor could result in dismissal from the program at any time.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Release Form
I, {main_name} give my permission for the Tusculum University Upward Bound Math and Science Program to use my image/likeness in or on Upward Bound Math and Science related publications and/or public relations materials.

Such items may include:
- Newsletter
- Video
- Website
- Handbook
- Brochures
- Newspaper
- All Social Media
I understand that these items will be used by the Tusculum University Upward Bound Math and Science Program to provide information about its services and activities.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Permission for Over the Counter Medications
For the convenience and comfort of our Upward Bound Math and Science
students, Upward Bound Math and Science staff have available certain nonprescription medications. Parental consent is required for students to receive
these medications.
Student Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
School
Grade
Allergies
Does your child have permission to receive over the counter medications as needed?

YesNo

What medications can we give your child? (Select YES or NO)

	YES	NO
Pain relievers (Tylenol, Aleve, Advil)
Digestive relief (Pepcid, Pepto, Imodium)
Motion Sickness Medication (Dramamine)
Cold/Sinus Medication (Tylenol Cold, Sudafed)
Allergy Medication (Benadryl)

Custodial Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Cell Phone
(999)999-9999
Home Phone
(999)999-9999
Work Phone
(999)999-9999
Emergency Contact

First NameLast Name
Phone
(999)999-9999