Virginia Union University-UBMS-Application Form

Virginia Union University ~ Upward Bound Math Science Program

NEW STUDENT APPLICATION
For questions or additional information, please contact:

Dr. Chanel Graves, Director
Ms. Sharna Gannaway, Academic Advisor
1500 North Lombardy Street | Baptist Memorial Building, 2nd Floor | Richmond, VA 23220
Phone: 804.257.5899 (office) | Email: ubms@vuu.edu
UPWARD BOUND MATH SCIENCE APPLICATION CHECKLIST
Please check the following boxes after you have completed each part of the application.

Student Section of the applicationParent Section of the applicationCompleted Recommendation Form from CounselorCopy of Transcript or most recent Report CardCopy of most recent Tax Returns
If you did not file taxes, please attach one of the following documents to verify income

• Copy of W-2 forms from the previous year or income from another governmental source
• A signed statement from the student’s parent/guardian regarding family income
• A signed financial aid application

What Happens Next?

1. After your completed application has been submitted, the staff will review your application. (Reminder: You are responsible for ensuring that both reference forms are filled out and returned with your application.)
2. You will receive an email from Upward Bound Math Science Team about the status of your application.
3. If you meet the minimum criteria, you will be interviewed by the Upward Bound Staff.

ATTENTION:
Your application will not be evaluated until you submit all of the above
information to the Upward Bound Math Science Office.

I. Student Section
Name*

First NameMiddle NameLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number: Home
(999)999-9999
Telephone Number: Cell
(999)999-9999
Telephone Number: Work
(999)999-9999
Email Address:*
example@example.com
Gender:

MaleFemale
Date of Birth:

MonthDayYear
mm-dd-yyyy
Grade:
Last four of Social Security Number:
9999
Ethnicity:

White (Non-Hispanic)Black or African AmericanHispanic or LatinoNative Hawaiian or Other pacific IslanderAsianAmerican Indian / Alaskan NativeOther
Are you:

U.S. CitizenAn eligible non-citizen (please provide a copy of immigration documentation)Non- U.S CitizenOther
High School Attending:
What is your current GPA:
Do you plan on attending college?

YesNoNot Sure
How did you hear about Upward Bound?

CounselorTeacherPresentationUpward Bound StudentOther
Are you currently enrolled in another college prep program (Upward Bound, Talent Search or Gear Up)?

YesNo
If an Upward Bound Math Science student referred you, what is their name?
Please circle the courses you have taken or are currently taken.

Algebra 1Algebra 2GeometryOther Math (Describe)
Please circle the courses you have taken or are currently taken.

Earth ScienceBiologyPhysicsChemistryOther Science (Describe)
Please circle the courses you have taken or are currently taken.

World History IWorld History IIWorld GeographyUS History GovernmentOther History (Describe)
Please circle the courses you have taken or are currently taken.

SpanishFrenchEnglish 9English 10English 11English 12

Please list any other courses you have taken or are currently taken

	Course
1.
2.
3.
4.
5.
6.
7.
8.

This is to certify that all information by me is true and correct to the best of my knowledge. Furthermore, I give Virginia Union University’s Upward Bound Math Science Program permission to receive copies of my education record and other materials necessary for participation in the program.
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy

II. Parent / Guardian Section
Parent / Guardian Information

This section must be completed by the student’s parent / guardian. If you have any questions, call the Upward Bound Math Science office at (804) 257-5899. Please complete all blanks to avoid processing delays.

Confidentiality of Information

No one is allowed to see the information you provide unless he/she is an employee of Virginia Union University Upward Bound Math Science Program or otherwise authorized to see this information. All information provided in this section is protected by the privacy Act and is not specifically reported to the federal government or U.S. Department of Education. However, the Department of education does have the authority to gather general statistical data about program participants in order to improve and measure the success of the Upward Bound Math Science Program.
Parent/Guardian :

First NameLast Name
Highest Education Level Completed:

Elementary or Junior High SchoolHigh School or GEDVoc./Technical SchoolSome CollegeAssociate’s DegreeCompleted Bachelors Degree
Parent/Guardian Martial Status

MarriedDivorcedSeparatedUnmarriedWidowed
Number of people in household: Adults
Number of people in household: Children
Employer’s Name:
Occupation:
Work Number:
(999)999-9999
Are you currently receiving public assistance:

YesNo
If yes please check the following:

WelfareSocial SecurityCompensationUnemploymentRetirementOther
Parent/Guardian :

First NameLast Name
Highest Education Level Completed:

Elementary or Junior High SchoolHigh School or GEDVoc./Technical SchoolSome CollegeAssociate’s DegreeCompleted Bachelors Degree
Parent/Guardian Martial Status

MarriedDivorcedSeparatedUnmarriedWidowed
Number of people in household: Adults
Number of people in household: Children
Employer’s Name:
Occupation:
Work Number:
(999)999-9999
Are you currently receiving public assistance:

YesNo
If yes please check the following:

WelfareSocial SecurityCompensationUnemploymentRetirementOther

List all dependents (including applicant) living in the household.

	Name	Age	Occupation
1
2
3
4
5
6
7
8
9
10

Taxable Income
IRS Form 1040, line 43, IRS Form 1040SR, line 15, IRS Form 1040EZ, line 10
I certify by signing below that all of the above information is correct and that any false or misleading information may result in the disqualification of the applicant.
Parent/Guardian Signature:

Clear
Date

MonthDayYear
mm-dd-yyyy

STUDENT INFORMATION RELEASE FORM
Permission to release information

For: {main_name}

I authorize The Virginia Union University Upward Bound Math Science Program
to receive copies of my Son’s/Daughter’s academic records, including, but not
limited to transcripts, grade reports, test scores, evaluations, attendance, medical
records, disciplinary actions, and other records necessary for participation in the
program. This information may be used for any federal reports of the Upward
Bound Math Science Team. This release is to be effective throughout my high school and college matriculation.
Student’s Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/ Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Virginia Union University ~ Upward Bound Math Science Program

UPWARD BOUND MATH SCIENCE APPLICATION CHECKLIST