Marian University-UBMS-Application Form

1. Student Applicant Information

Marian University's Upward Bound Math and Science (UBMS) program is a federally funded TRIO educational program. We are required to determine whether our applicants meet the criteria of first-generation college and/or financially qualified status prior to their acceptance into the program. The information collected via this form will be kept confidential. Upon reception of this application, a member of the team will contact you to collect additional information that may be needed as part of this process.

Watch this video to learn more about UBMS

1. Student Name*

First NameMiddle InitialLast Name

2. Contact Information

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Email Address*

example@example.com

Preferred Phone Number

(999)999-9999

3. Date of birth*

mm-dd-yyyy

4. Sex at Birth*

MaleFemale

5. Ethnicity (Not Required)

This information is being requested in accordance with Federal regulations. The information is voluntary and will not be used when considering you for acceptance into the UBMS program.

6. Citizenship or Residency Information*

US CitizenUS Permanent Resident

Non-U.S. Citizens, please provide your Alien Registration Card (A#)

7. Do you have a documented disability?

YesNo

If you have a documented disability, UBMS staff will follow up with you for additional
information.

8. High School Enrollment Information*

Fond du Lac High SchoolHorace Mann High SchoolOther

9. Grade Level*

9th10th11th12th

10. What is your overall GPA to date?

11. Current School Counselor's Name

Name

First NameLast Name

Email

example@example.com

Phone Number

(999)999-9999

PROGRAM ELIGIBILITY CRITERIA

A first generation college student is one whose neither parent has received a Bachelor's degree or higher at the time of entry into the UBMS program.

12. First Generation Status.*

YesNo

13. Father's highest level of education*

14. Mother's highest level of education:*

15. Income Status

Very Important - To determine eligibility based on income status, please refer to this income levels chart (https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html) provided by the U.S. Dept. of Education. For any question about this section of the application form, please be in contact the UBMS program to determine eligibility to the program.

Following the submission of this form, parent(s)/guardian(s) will be contacted for verification of income.

To verify income status, UBMS staff will request a signed copy of parent(s)/guardian(s) Income Tax Return (Form 1040, 1040A, or 1040EZ) for the previous calendar year. If this is not available, parent(s)/guardian(s) will be asked to sign a statement regarding their student's eligibility based on their income level. The income to be considered is the taxable income (not the federal adjusted gross income) of the household that has custody of the student.

The application process is not considered complete until income status information has been received by a designated UBMS staff. Requested financial paperwork, as required by law, must be submitted prior to an interview and admittance to the program.

How many family members are living at home?*

Did your supporting parent(s)/guardian(s) file income taxes last year?*

What was your family's total taxable income (not the overall gross income)?*

(Form 1040 Line 43; Form 1040A Line 27; Form 1040EZ Line 6)

STUDENT INTERESTS QUESTIONNAIRE

INSTRUCTIONS: Please answer the following questions using complete sentences. Considerable thought and effort should be given to the responses.

16. How and where did you hear about the UBMS program? Who/what inspired you to apply for it?

17. What are some things you have done that you are very proud of?

18. What are some of the most challenging subjects or issues for you in school?

19. Do you want to pursue either a 2-year or 4-year college degree? Please provide your reasons.

20. What career or profession do you want to have when you graduate from college?

21. In what ways do you think your participation in UBMS will be beneficial/helpful to you?

EXTRACURRICULAR ACTIVITIES QUESTIONNAIRE

INSTRUCTIONS: Please answer the following questions, using complete sentences. Considerable thought and effort should be given to the responses.

22. Please list school, community clubs, organizations, sports that you are currently involved in.

23. Please list jobs or volunteer work you have done. Include church, community service, and school or family jobs. What did you learn from these experiences?

24. Describe your special interests and hobbies, what do you like to do after school or on weekends?

PARENT/LEGAL GUARDIAN INFORMATION

25. Mother/Guardian information

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number

(999)999-9999

26. Father/Guardian Information

Name

First NameLast Name

Address (If both parents have the same address, write “Same as above”.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number

(999)999-9999

EMERGENCY CONTACT INFORMATION

Please provide the information for three contacts, in addition to parents/legal guardians listed above.

27. Emergency Contact #1

Name

First NameLast Name

Relationship

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number

(999)999-9999

28. Emergency Contact #2

Name

First NameLast Name

Relationship

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number

(999)999-9999

29. Emergency Contact #3

Name

First NameLast Name

Relationship

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number

(999)999-9999

RECOMMENDATION FORMS

Recommendation forms are very important components of your application to the UBMS Program. Therefore, you must submit two recommendation forms. The first of these recommendations must be from a school counselor, administrator, coach, or student services staff member. The second one must be completed by a current or a previous teacher of any discipline who knows you well; preferably a math or science teacher.

You are highly encouraged to speak directly to the person who will recommend you. Tell them about your interests in applying for the UBMS Program. This may help them adequately assess your potential to succeed as a participant.

For administrative records, please indicate the names and titles of all those who will recommend you to the UBMS Program.

30. Two recommendations in support of your application.

Include one of each of the types listed below:

Recommendation 1: School Counselor, Administrator, Coach, or Student Services

First NameLast Name

This may be someone who knows you either in high school or in middle school.

Email

example@example.com

Title

Recommendation 2: Current or a previous Teacher of any discipline

First NameLast Name

Email

example@example.com

This may be a teacher from any discipline.

Title

STUDENT AND PARENT(S)/GUARDIANS APPROVAL AND SIGNATURE

Please understand that Marian University's Upward Bound Math and Science administrative staff respects the confidentiality of each applicant as well as their family. Considerable care is taken to ensure that personal and family information is not publicly accessible.

We understand that Marian University's Upward Bound Math and Science program will use the data provided on this application for to assist in assessing the student’s academic and career planning needs.
We understand that all information provided on this form will be kept and used in the strictest confidence.
We certify that all information provided on this form is correct to the best of our knowledge.
By submitting this form, we give permission for Marian University's UBMS staff to access the aforementioned student’s academic records and give permission for any school that our student attends to release those records to UBMS Staff. The information will be used to determine student eligibility and potential for success in the project.
By submitting this form, we agree to be contacted by a Marian University staff who will collect all the required signatures necessary for this process.

Student Signature

Date

mm-dd-yyyy

Parent Signature

Date

mm-dd-yyyy

UBMS Participant Application