2024-2025 Upward Bound Math & Science Application for Admission

TELEPHONE: If no home/work phone number is available, you must provide an alternate name and number for messages.

Have you ever participated in any of the following programs?

(Complete if applicable.)

One of the criteria for admission to the UBMS program is meeting the income guidelines established by the U.S. Department of Education. Before UBMS can determine your son or daughter’s eligibility, the program needs the following information. Please read carefully and complete all parts. If all information is not completed, the form cannot be processed. Please complete the following information as accurately as possible to determine economic eligibility. All information is kept confidential.

Please place a checkmark in the blank below which indicates your taxable family income last calendar year. (To determine your income, refer to the “taxable income” line of your Federal tax return, Line 15 on the 1040 form. Taxable income IS NOT your gross or take home pay. Be sure to refer to your most recent tax return for this information.)

Please select the option which indicates your taxable family income last calendar year. (To determine this, refer to the "taxable income" line of your Federal tax return. Line 15 on the 1040 form. Taxable income IS NOT your gross or take home pay. Be sure to refer to your most recent tax return for this information.

I understand the goals, objectives, and requirements of the UBMS program and agree to fulfill them. I also understand that if I do not fulfill the required goals and objectives, I will be terminated from the program. I certify that all the information I have provided is valid and correct to the best of my knowledge.

I understand the goals, objectives, and requirements of the UBMS Program and agree to support my child in fulfilling them. I also understand that if my son/daughter does not fulfill the required goals and objectives, he/she will be terminated from the program. Additionally, I certify the income provided on this application is an accurate statement of the income eligibility required for my son/daughter to be a participant in the TRIO Upward Bound Math and Science (UBMS) program. I understand that UBMS staff will use the data provided on this application to assist in determining my son/daughter’s eligibility for the program. I certify that all the information I have provided is valid and correct to the best of my knowledge. My signature signifies that I have read and understand this statement and that I am signing free of force or duress.

DIRECTIONS: The following section is to be completed by the student. This is not an exam with “right” or “wrong” answers but rather an opportunity to express your opinions and attitudes about school, your career interests, your needs and abilities, and your future. This information will be reviewed by the selection committee to determine if the services of the TRIO Upward Bound Math Science program will be beneficial to you. Honest and accurate information is very important.

STUDENT QUESTIONNAIRE: Please evaluate the following statements depending on if you would need assistance with any of these topics at any point during your high school career. Place a check mark in the appropriate box.

I understand that the purpose of the TRIO Upward Bound Math & Science (UBMS) program is to prepare participants to successfully complete a four-year college program. As part of my personal effort in this preparation, I commit to the UBMS staff to do the following:

All Participants:

1. I will attend school daily unless a parent/guardian has properly excused the absence. An excessive number of absences, either unexcused or excused, will not be acceptable.
2. I will have and maintain an acceptable grade point average of 2.75 or better and show progress each semester thereafter. If I enter the program with less than a 2.75, I understand that I may be put on hold or on probation until improvement is shown or until this requirement is met.
3. I will enroll in math and science classes each year in high school.
4. I will register for and take the ACT by the end of my junior year and/or the beginning of my senior year.
5. I will attend the UBMS Summer Academy for the entire duration of the program.
6. I will follow all UBMS policies and submit all program paperwork on time. Paperwork includes permission slips, progress reports, report cards, ACT and other test scores, and college and financial aid papers. By participating in UBMS I give consent for the release of my postsecondary enrollment records to UBMS.
7. I will enroll in a rigorous curriculum as identified by the Kentucky Board of Education to prepare for college.
8. I will continue to participate in UBMS until I graduate from high school.
9. I will graduate from high school and enroll in college the semester following my graduation.
10. I will communicate with the UBMS staff while enrolled in college.
11. I understand if my GPA is below 2.75, I am required to attend tutoring sessions unless involved in a school-sponsored extracurricular activity for which the appropriate waiver will be on file.
12. I will attend both a summer non-residential component and an academic year component.
13. I will participate in no less than 75% of all activities planned for the year including Saturday Sessions.
14. I may miss these sessions only if I am involved in a school-related activity that conflicts with the session or for illness or family emergency. I understand that missing these sessions for work is not acceptable. Only if UBMS changes the date of/or adds a session will I be excused if a work conflict occurs.
15. I will attend meetings and appointments arranged with the UBMS staff member to discuss my academic progress, attendance, etc.

I understand that repeated failure to comply with these guidelines will result in my expulsion from the TRIO Upward Bound Math and Science program. Special activities offered by UBMS are privileges. Failure to meet the guidelines and expectations of UBMS may result in exclusion from these activities.

I understand that acceptance into the TRIO Upward Bound Math and Science (UBMS) brings responsibilities for my son/daughter but will also require my support and participation. The following defines (but does not limit) my responsibility as a UBMS parent:

1. I grant permission for my son/daughter to participate in the UBMS Academic Year and Summer Programs. I understand the UBMS expectation for my child to participate in both programs.

2. I will attend Parent/Student Workshop: i.e family night etc. at my son/daughter's during the Fall and Spring Semesters.

    

3. I will attend a minimum of two (orientation and/or family night) UBMS-sponsored activities.

    

4. I will attend the scheduled orientation meetings as required.

    

5. I will contact the UBMS office before any UBMS activity for which my son/daughter will be absent.

    

6. I will support the UBMS by volunteering when possible.

    

7. I agree to cooperate with the UBMS staff regarding my son/daughter’s academic progress and goals for improvement.

    

8. I understand that I am to take an active role in seeing that my child is fulfilling the UBMS program requirements. Students who do not fulfill the requirements face probation and/or expulsion from the program. In some cases, counseling may be required for a student to continue in UBMS.

    

9. I assume responsibility for any damage brought about by my child to the UBMS technology, the college, or other facilities.

    

10. I understand that my child may be dismissed from UBMS for failing to comply with the UBMS regulations. Immediate removal from the UBMS program will occur if my child is in possession of tobacco, alcohol, drugs, firearms or other weapons during program activities.

     

11. I understand that my child will be sent home at the expense of my family if he/she violates the UBMS rules during a UBMS trip/activity.

Statement of Acceptance:

I have read and understand the responsibilities and expectations my son/daughter is undertaking by joining the TRIO Upward Bound Math & Science program. I agree to support my son/daughter in achieving his/her goal of graduating from high school and pursuing a college education by meeting the “Parent Agreement” as listed above.

DIRECTIONS: This form must be completed by the student and the parent/guardian.

The U.S. Department of Education requires that the TRIO Upward Bound Math & Science (UBMS) program at Elizabethtown Community & Technical College (ECTC) follow and monitor the academic progress of students participating in UBMS by tracking secondary school graduation, college matriculation, persistence and subsequent college graduation, etc. The information provided in this application is necessary to determine eligibility for the program. Only UBMS, ECTC personnel, and U.S. Department of Education personnel have access to these records.

1. I give consent to release the following information to the Elizabethtown Community and Technical College Upward Bound Math and Science program as requested:

   1. Standardized Test Results (ACT, SAT, CTBS, PSAT, etc.)

   2. High School Grade Reports

   3. High School Transcripts

   4. College Admission and Financial Aid Records

   5. College Grade Reports and Transcripts

2. Further, I give consent for UBMS/ECTC staff and my child’s school representatives to discuss my child’s academic progress and general school activities for the purposes of identifying needs, coordinating services, and documenting my child’s overall scholastic progress. I and my child fully understand that UBMS will track my child’s academic progress and admission status until he/she is no longer attending an institution of higher education.
3. I give consent for UBMS/ECTC to use photographs of my child for news releases, publicity, and other information about the program released to the public.

This permission is granted for a period of time not to exceed ten (10) years after secondary school graduation or until this authorization is specifically canceled by both {studentName134} and his/her parent or guardian.

As a result of signing this form, the student applicant and his/her parent/guardian certify that they are providing this authorization with full understanding and voluntarily in consideration of the student applicant’s participation in the TRIO UBMS program at ECTC and to permit the UBMS program to fulfill requirements imposed by the U.S. Department of Education, the funding agency. The records secured with this Release will not be shared with any third party in accordance with FERPA.

NOTE: Information obtained by this form shall not be transferred to any other person or agency than that listed above without the consent of the person whose signature appears here on.

 

SCHOOLS: Current school may retain a copy of this form for student files.

Please include the name and email of two Teachers or Counselors (or one of each) you wish to recommend you for our program. If a teacher will complete the recommendation form, a math or science teacher is preferred, but not required.