Baltimore City Community College-UBMS-Application Form

Baltimore City Community College Upward Bound Math/Science Program

STUDENT APPLICATION
This application must be completed by parent(s)/guardian(s) and student.
- Name
  
  First NameMILast Name
- Social Security Number
  999-99-9999
- Last 4 digits of your social security number
  9999
- Grade
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home #
  (999)999-9999
- Cell #
  (999)999-9999
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Age
- Gender
- CITIZENSHIP:
- Are you a U.S. Citizen?
- If NO - Are you a Permanent Resident?
- Student E-mail:
  example@example.com
- Guardian E-mail:
  example@example.com
- ETHNIC BACKGROUND
  
  Other
- GUARDIAN INFORMATION: Student lives with:
- MOTHER/FEMALE GUARDIAN: Income and Occupation
- Name
  
  First NameLast Name
- Title/Occupation:
- Telephone #:
  (999)999-9999
- Annual Gross Income: $
- FATHER/MALE GUARDIAN: Income and Occupation
- Name
  
  First NameLast Name
- Title/Occupation:
- Telephone #:
  (999)999-9999
- Annual Gross Income: $
- Total number of persons living at home dependent on the income listed above: (including parents)
- Annual Total Family Gross Income: $
- FIRST GENERATION STATUS Parent(s) Guardian(s) Education
  
  MOTHER/FEMALE GUARDIAN:
- Graduated High School
- Earned Bachelor's Degree (earned a 4-year degree)
- FIRST GENERATION STATUS Parent(s) Guardian(s) Education
  
  FATHER/MALE GUARDIAN:
- Graduated High School
- Earned Bachelor's Degree (earned a 4-year degree)
- EMERGENCY NOTIFICATION INFORMATION
  
  Emergency Contact #1 (Other than Guardian(s)
- Name:
  
  First NameLast Name
- Relationship:
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip
- Telephone:
  (999)999-9999
- EMERGENCY NOTIFICATION INFORMATION
  
  Emergency Contact #2 (Other than Guardian(s)
- Name:
  
  First NameLast Name
- Relationship:
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip
- Telephone:
  (999)999-9999
- MEDICAL DISABILITIES OR SPECIAL CARE REQUIRED INFORMATION
- Does your child have any disabilities or medical conditions that may require redical treatment or medicine?
- Name of High School
- Counselor's Name
- School Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- School Telephone Number
  (999)999-9999
- G.P.A.
- PSAT Score
- ACT Score
- SAT Verbal Score
- SAT Math Score
- THE FOLLOWING MUST BE SUBMITTED WITH THIS APPLICATION:
  
  ; Teacher’s Evaluation and Counselor’s Recommendation
  
  ; Personal Goals Statement
  
  Describing your educational and life goals, and explain how participating in the BCCC Upward Bound Math/Science Program will help you achieve these goals (2 to 3 paragraphs)
  
  ; Current Report Card and Transcript
  
  ; Birth Certificate and Social Security Card
  
  ; Copy of parent’s most current Federal Income Tax Form (1040 tax form)
  or a copy of Grant or Benefits Letter
  
  ; YOU MUST have this statement Notarized
- Teacher Evaluation
  
  Cancelof
- Counselor's Recommendation
  
  Cancelof
- Current Report Card
  
  Cancelof
- Transcript
  
  Cancelof
- Birth Certificate
  
  Cancelof
- Social Security Card
  
  Cancelof
- Copy of parent’s most current Federal Income Tax Form (1040 tax form)or a copy of Grant or Benefits Letter
  
  Cancelof
- PARENT(S) GUARDIAN(S) PLEASE READ BELOW AND SIGN BELOW:
  
  In applying for a federally funded program, you should know that anyone making false statement or misrepresentation in establishing eligibility is subject to a fine or imprisonment or both under provisions of the U.S. criminal code.
  
  ; I certify the information provided is correct to the best of my knowledge.
  
  ; I will participate in all Upward Bound activities requiring my presence and promise to attend at least six parent meetings during the year.
  
  ; I give consent for my child to use public or private transportation for off-campus activities.
  
  ; I authorize my child’s high school to release grade reports, transcripts, and any other pertinent material now and throughout the duration of high school to the BCCC Upward Bound Math/Science Program.
- Parent/Guardian Name
  
  First NameLast Name
- Parent/Guardian Signature
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Notary Name
  
  First NameLast Name
- Notary Signature
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Describe your educational and life goals, and explain how participating in the BCCC Upward Bound Math/Science Program will help you achieve these goals (2 to 3 paragraphs)
  
  Essay must be completed by the applicant only without any assistance.
- Student's Name:
  
  First NameLast Name
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Type essay here...
- Please provide a brief answer to the question listed below.
- What do you consider to be your greatest academic strength?
- What do you consider to be your most worthwhile accomplishment(s)?
- In what extracurricular activities/sports do you participate?

Baltimore City Community College Upward Bound Math/Science Program