Northern Arizona University-UBMS-Application Form

2022-2023 New Student Application Upward Bound Math & Science
UBMS is a federally funded college preparation program at Northern Arizona University. This year-round high school program serves underrepresented students who reside in a low-income household and/or are a potential first-generation college student. Starting in 2022, students may receive services from the Flagstaff healthcare and human services center, Native Americans for Community Action (NACA).

We aim to recruit students who have decided to work towards a college degree. UBMS provides a safe and inclusive environment for students to learn relevant academic and life skills to become a healthy student and young adult.

How to Apply: Complete all fields of this application packet

New Student Recruitment Application Timeline:
- August 2022: Application is open. Deadline is Thursday, December 1st, 2022.
- January 2023: UBMS will update students & family via email about their application status.
- May 2023: Newly accepted students & family attend an UBMS Welcome Orientation.
- June 2023: All students attend the summer program orientation and 5-week summer program at NAU.

Student Eligibility Requirements:

1. You are a freshman or sophomore student enrolled at a UBMS target school listed below,

Coconino High School: Amanda Stalvey, Chemistry Instructor- astalvey@fusd1.org

Holbrook High School: Donna Campbell, Academic Advisor- dcampbe@holbrook.k12.az.us

Many Farms High School: Shawn Deschenie, Counselor- tullus.deschenie@bie.edu

Bobbie Bekay, Counselor- bobbie.bekay@bie.edu

Monument Valley HS: Brian Bradley, Counselor- Brian.Bradley@kayenta.k12.az.us

Tuba City High School: Cheryl Onsae, Counselor- consae@tcusd.org

2. You have a 3.0 or higher GPA, meaning mostly A or B grades in all classes.
3. You are a potential first-generation student (neither of your parents have a 4-year college degree).
4. You reside in a low-income household.
5. You are not already participating in another NAU or non-NAU Trio program, such as, Talent Search, Upward Bound, Nizhoni, etc.

Applications are due 12/01/2022
Student’s Personal Information
2022-2023 New Student Application

Student Applicant’s Contact Information
Full Legal Name:*

First NameMiddle InitialLast Name
Preferred Pronouns:
Preferred Name:

First NameLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number:
(999)999-9999
Can you receive text messages?

YesNo
Preferred Email Address:*
example@example.com
Federal Funding Information
Date of Birth:

MonthDayYear
mm-dd-yyyy
Social Security Number:
999-99-9999
Gender:

FemaleMale
Ethnicity (check all that apply):

AsianHispanicAmerican Indian/Alaskan NativeNative Hawaiian or Pacific IslanderWhiteBlack or African AmericanOther
Tribal Affiliation:
Student’s Proof of Citizenship and Residency
Are you a/an,

United States CitizenPermanent Resident of the United States: Immigrated to the U.S. Applied and achieved permanent residency.Intending to become a United States residentOther (please explain):
Please attach a copy of one of the below documents showing proof of citizenship and residency.

1. Immigration and Naturalization Service documentation of intent to establish permanent residency
2. Certificate of Indian Blood (CIB), Bureau of Indian Affairs Card Number or Tribal Enrollment Number
3. Birth Certificate showing applicant was born in the United States or U.S. passport (current or expired)
File Upload

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Student’s High School Information
High School Name:
Grade Point Average:
Current Grade Level:

FreshmanSophomore
Expected Graduation Year:
Current Math Class:
Current Science Class:
Name of Counselor:

First NameLast Name
Counselor’s Email:
example@example.com
Select classes you are currently enrolled in.

AP ClassesPre-AP ClassesDual EnrollmentHonors ClassesTech Prep
What student clubs/organizations or sport teams are you active in:
How did you hear about the UBMS program?
Student's Name

First NameLast Name
UBMS Student Agreement & Guidelines
2022-2023 New Student Application

I, {studentsName}, agree that if I am accepted to the Upward Bound Math &
Science Program at Northern Arizona University, I will:

1. Abide by all rules and policies of UBMS, program partners and Northern Arizona University.
2. Work to maintain a 3.0 GPA every semester by completing each class with a B grade or better.
3. Maintain good attendance, be punctual, participate in class, complete homework, and all other class requirements.
4. Attend each UBMS program meeting, class, and events during the school year and summer.
5. Complete all assigned activities and assignments thoughtfully and seriously.
6. Meet with my program and school advisor, counselor, mentors, and facilitators when scheduled.
7. Abide by UBMS and school attendance policies.
8. Take advantage of academic tutoring tools to comprehend class topics and to seek help before my grades are not meeting appropriate academic standards.
9. Work with and cooperate with all hired and volunteer staff working with UBMS.
10. Remain active in UBMS every summer and every semester through my high school graduation.
11. Plan and complete a post-secondary education program after high school graduation.
12. Stay in contact with UBMS after graduation to provide follow-up data about my path in obtaining a college degree.

UBMS staff may communicate with me, the student, and my parents/guardians, using the following tools,

- Facebook and other social media platforms
Text messaging and phone calls
- Email messaging and U.S. postal mail
Student’s Full Name

First NameLast Name
Student’s Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Personal Information
2022-2023 New Student Application

Primary Parent/Guardian Contact Information
What is your relationship to the student?
Full Legal Name:

First NameMiddle InitialLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number:
(999)999-9999
Can you receive text messages?

YesNo
Preferred Email Address:
example@example.com
Secondary Parent/Guardian Contact Information
What is your relationship to the student?
Full Legal Name:

First NameMiddle InitialLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number:
(999)999-9999
Can you receive text messages?

YesNo
Preferred Email Address:
example@example.com
Parent Status:

Parents live togetherParents are separated/divorcedFather deceasedMother deceasedBoth parents deceased
With whom does the student live?

Mother onlyFather onlyMother and FatherMother and StepfatherFather and StepmotherOther
Financial support from Parents:
If student does not live with both of their natural or adoptive parents, have they received financial support from the other parent?

YesNoNot Applicable
Parent/Guardian Income Affidavit for 2021 Tax Year
2022-2023 New Student Application

Certification: All of the information on this application is true and correct to the best of our knowledge. If asked by an authorized official, we agree to give proof of the information that we have given on this application. The Upward Bound Math & Science program at Northern Arizona University is required by federal law to report cases of suspected fraud to appropriate law enforcement agencies for investigation.
How did you file your 2021 income tax?

Married, filing jointlyMarried, filing separatelyHead of householdOther
Head of Household: check all for which you qualify
You

65 years or olderBlind
Spouse

65 years or olderBlind
Total number of people in household (including head of household):
Sources of Income

- If you are married, and filed jointly, include your spouse’s income.
- Enter a dollar amount in every box.
- Enter a zero in each category where no income was earned.

Sources of Income

	Mother/Primary Guardian’s Income	Father/Secondary Guardian’s Income
Print Full Name:
Amount from Employment (Yearly) $
Alimony (Yearly) $
Social Security (Yearly) $
Unemployment (Yearly) $
TANF (Yearly) $

State all other sources of income below

	Source	Mother/Primary Guardian’s Income	Father/Secondary Guardian’s Income
1
2
3

Parental/Guardian Consent: I give my permission to any, and all, public assistance programs to release the necessary information to verify the above income (i.e., Social Security Benefits Programs, Food Stamps, School Lunch Programs, and/or Welfare/General Assistance Programs).
Primary Parent/Guardian:
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Secondary Parent/Guardian:
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Questionnaire
2022-2023 New Student Application

Thank you for encouraging your child to apply to the UBMS Program. Answer each question honestly and with exact details when possible. Attach additional sheets if necessary.

First-generation status

UBMS defines first-generation as meaning, neither parent/guardian have a four-year college degree or higher. If you, the parent/guardian, attended a four-year college, but did not complete the degree, your child is still considered a first-generation student.
The natural/adoptive mother’s highest level of education (check only one)

Some high schoolHigh school degree/GEDSome collegeAssociate’s degree (2 years)Bachelor’s degree (4 years)Master’s or Doctorate degree
The natural/adoptive father's highest level of education (check only one)

Some high schoolHigh school degree/GEDSome collegeAssociate’s degree (2 years)Bachelor’s degree (4 years)Master’s or Doctorate degree
Parent/Guardian Observations
Name of Parent/Guardian answering questions:

First NameLast Name
1. What do you see are your student’s strengths? (academic, personal, social)
2. In what areas does your student need to improve?
3. What are your child’s plans after high school?
4. What concerns or questions do you have about your child getting through high school and into college?
School Records Release Form

Student Permission:
Student's Name:

First NameLast Name
I, {studentsName92}, hereby consent to the release of my academic records,
including but not limited to, transcripts, grade reports, test scores, course evaluations, attendance records, recommendations and other information regarding my school performance to-- Northern Arizona University Upward Bound Math & Science Program. This release is to be effective throughout my high school, and college career and includes my final transcripts upon graduation from secondary school and college. It is effective regardless of whether or not I am actively involved with Upward Bound Math & Science at the time of the records request.
Student's Printed Full Name:

First NameLast Name
Student’s Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
High School
ID Number
Parent/Guardian Permission:
As the parent/guardian of {studentsName92}, I hereby consent to the release of my child’s academic records – including but not limited to transcripts, grade reports, test scores, course evaluations, attendance records, recommendations and other information regarding their school performance to-- Northern Arizona University Upward Bound Math & Science Program. This release is to be effective throughout their high school, and college career and includes their final transcripts upon graduation from secondary school and college. It is effective regardless of whether or not they are actively involved with Upward Bound Math & Science at the time of the records request.
Parent’s Printed Full Name

First NameLast Name
Parent’s Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Student Applicant’s Needs Assessment
Must be completed by the student applicant. Check “Yes” or “No” to each question
1. Have you ever thought about dropping out of school?

YesNo
2. Are you currently participating in any other programs such as Upward Bound, Educational Talent Search, etc.?

YesNo
If yes, please provide the name of the program.
3. Do you participate in any extracurricular activities?

YesNo
4. How often do you meet with your high school counselor each semester?

012345+
5. Do you know the correct high school classes to take to prepare for college?

YesNo
6. Do you need tutoring?

YesNo
7. Have you decided on a career?

YesNo
If so, your career choice is
8. Do you know what courses you should take for the career you want to pursue?

YesNo
9. Are you able to take all the science and math courses you need at high school?

YesNo
10. Do you need assistance in improving your math skills?

YesNo
11. Do you need assistance in improving your science skills?

YesNo
12. Do you need help in “study skills?”

YesNo
13. Do you need help with your organization of school work and assignments?

YesNo
14. Have you begun preparation for the ACT/SAT or Pre-ACT/Pre-SAT tests?

YesNo
15. How many years of college do you plan to complete after high school graduation?
16. Have you attempted to contact the college of your choice for information?

YesNo
17. Do you know the procedures to enroll in the college you plan to attend?

YesNo
18. Do you need help in applying for college?

YesNo
19. Do you have information about college financial aid programs?

YesNo
20. Do you know how to apply to financial aid or for scholarships?

YesNo
21. Do you need help in applying for scholarships?

YesNo
22. Do you personally know anyone with a career in math or science other than teachers?

YesNo
Student Applicant Personal Essay
2022-2023 New Student Application

You must complete a personal essay as part of your application. Essays can be typed as a Word or Google Document and uploaded below: include your name, date, and your school year. You can SAVE and RETURN to this application at any time to UPLOAD your completed essay BEFORE SUBMITTING your application. OR you can complete your essay in the space provided below. Your essay should be appropriate in length while thoughtfully answering the prompts below:

1. Who are you, what makes you unique and special?
2. Describe your family, friends, and community. How do they mold who you are?
3. What do you hope to gain from joining the NAU UBMS program?
4. Why do you want to go to college? What are you doing now to work towards that goal?

Writing Style Tips

• Create an essay outline.
• Start with your introduction. Your opening sentences should capture the reader’s attention.
• The body paragraphs should answer the prompts supported with personal evidence from your life.
• Be specific and be descriptive. We want to meet the real you.
• End your essay with a conclusion. Share the lessons learned from the experiences shared.
• Proofread your essay by reading it out loud. Use correct grammar, spelling, capitalization, and punctuation.
• Have an English teacher proofread your essay
Personal Essay
Student's Personal Essay:

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Recommendations
English Teacher Name

First NameLast Name
English Teacher Email
example@example.com
Math Teacher Name

First NameLast Name
Math Teacher Email
example@example.com

2022-2023 New Student Application Upward Bound Math & Science

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