Compton Community College-UBMS-Application Form

Compton College Upward Bound Math Science Program - 2024-2025 Admissions Application
Student:

First NameLast Name
Date:

MonthDayYear
mm-dd-yyyy
Thank you for your interest in the Compton College, Upward Bound Math Science program (UBMS). The information you provided on the Pre‐Screening Questionnaire indicates that you are eligible to participate in our program.

You are responsible for submitting your completed application by the due date.

Once your application is complete, we will arrange for an interview with you and your parent(s)/guardian(s).
If you have any questions, please contact us at (310) 900-1600
Xochilt Vega EXT 2205

Diana Chavez EXT 2750
Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Cell Phone Number
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
mm-dd-yyyy
Birthplace (City and State)
Gender

MF
Ethnicity
Ethnicity
High School
High School
Class of
Counselor

First NameLast Name

Please fill in the spaces below for all the members of your household. (Include yourself)

	Name	Relationship	Age	Grade*	School
1
2
3
4
5
6
7
8
9
10

*or highest grade/year in school/college completed. Please attach another piece of paper if necessary.
What languages are spoken in your home?
Have you or any of your siblings been enrolled in a UBMS Program?

YesNo
If yes, who?
Where/when?
Are you or any of your siblings in another outreach program? (ETS, UB, EAOP)

YesNo
If yes, who?
Which program(s)?
Are you involved in extra-curricular activities at school? (Clubs, athletics, etc.)

YesNo
If yes, describe: (Which club, sport?)
Day(s) & Time(s) of activities:
Do you have a job?

YesNo
If yes, where?
Position:
Day(s) & Time(s) you work:
Please answer the following questions as honestly and specifically as possible.
Why would you like to participate in the UBMS program?
What class(es) or subject(s) do you struggle with? What can the UBMS program do for you?
What do you do with your free time (include all extra‐curricular activities: hobbies, sports, clubs, student government, community service, church groups, etc.)?
Are you willing to participate in academic counseling meetings at your school?

YesNoNot Sure
If no or not sure, please explain:
Are you willing to participate in tutoring for each academic subject in which you earn a grade of “B-“ or below?

YesNoNot Sure
If no or not sure, please explain:
Are you willing to participate in Saturday Academy at Compton College 1x a month during the school year?

YesNoNot Sure
If no or not sure, please explain:
Are you willing to participate in the mandatory six-week program?

YesNoNot Sure
If no or not sure, please explain:
STUDENT CERTIFICATION

If selected as a participant of the Compton College, Upward Bound Math Science program, I agree to fully participate in the program until I graduate from high school. I agree to conduct myself in a respectful and responsible manner. I agree to positively represent myself, my family, school, community, and the Upward Bound Math Science program. I also agree to abide by the rules and regulations established by the program.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Name of Student

First NameLast Name
Date of Birth

MonthDayYear
mm-dd-yyyy
Class of
REASON for release of records and/or personal information:

My child is a participant in the Comptom College, Upward Bound Math Science program.

My child is a participant in the Compton College, Upward Bound Math Science program. The U.S. Department of Education requires the Upward Bound Math Science program to track participants’ academic progress until high school graduation. Therefore, the program will need records and/or information about my child to be released for the following school years:
- 2024-2025
- 2025-2026
- 2026-2027
- 2027-2028
The following information and/or documentation will be requested (as needed) by the program.
- Grades (Most recent academic semester)
- Standardized Test Scores
- Transcripts
- Class Schedule
I hereby authorize the release of records of my child (named above) to the Upward Bound Math Science program.
Name of Parent/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
(999)999-9999
Signature of Parent/Guardian

Clear
This electronic signature qualifies as your agreement to the terms set forth by this official document.
Date

MonthDayYear
mm-dd-yyyy
Cell Phone Number
(999)999-9999
Name

First NameMiddle InitialLast Name
INSTRUCTIONS: Please write a brief autobiography. Include information about your family background, educational and career goals, and anything else that may be helpful in giving us a more complete picture of you. Please attach this autobiography to your completed application. You may use additional paper if necessary.

Compton College Upward Bound Math Science Program - 2024-2025 Admissions Application