New Student Application TRiO Upward BOUND Math and Science Program Pima Community College Desert Vista Campus

The U.S. Department of Education requires the collection of the following information to determine student eligibility. Failure to provide the necessary supporting documents will result in your application being disqualified from consideration. All information you provide to the UBMS program is confidential and protected under the Privacy Act of 1974 (5 U.S.C. § 552a).

Citizenship Status:

First Generation Status:

Income Status:

THIS APPLICATION REQUIRES EITHER A RECENT TAX RETURN FORM and/or SIGNED INCOME STATEMENT FORM.

FOSTER CARE NOTE: If the student is in foster care or under the care of the Division for Youth or another institution, parental income information is not required. However, written verification of the student’s status must be provided by the appropriate agency. Foster parents may sign the application.

*PLEASE NOTE THAT UBMS RESERVES THE RIGHT TO REQUEST & REVIEW ADDITIONAL INCOME DOCUMENTATION FOR VERIFICATION.

The personal essay is a vital part of the UBMS selection process. Please write a minimum of 250 words in the space provided below. Be sure to include your interest in math or science, as well as your college and career goals. Choose ONE of the following prompts to guide your essay:

Choose ONE of the following questions:

1) What motivates you to apply to the UBMS program? What benefits do you hope to gain from this experience, and how do you plan to contribute to the program?

2) What events or individuals in your life have influenced your educational and career goals?

3) Discuss a personal, local, national, or international issue that concerns you.

4) What are your dreams for the future?

In accordance with the TRIO Upward Bound Math and Science (UBMS) Program eligibility requirements set forth by the U.S. Department of Education, I hereby certify and attest, under penalty of perjury, that the information I have provided on this application is true and correct to the best of my knowledge.

I authorize the UBMS program at Pima Community College, Desert Vista Campus, to access my student's academic and personal information through the school or district database and/or to receive copies of transcripts, test scores, and any other records necessary for participation in the program. I further authorize UBMS staff to access my student's college enrollment, retention, and completion information, as well as financial aid information from colleges and the federal government. I also certify that I am aware that providing false, fictitious, or fraudulent information, or omitting any material facts, may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims, or other violations.

(U.S. Code Title 18, Section 1001; Title 20, Section 1097; and Title 31, Sections 3729–3730 and 3810–3812)

This consent shall remain valid for the duration of my son/daughter’s participation in the UBMS program and until the completion of a bachelor's degree, or for six (6) years following high school graduation. whichever comes first. I hereby grant permission for my son/daughter to participate in the year-round UBMS program at Pima Community College, Desert Vista Campus. I also give my consent for the following:

• High school staff and administration to provide UBMS staff access to my student’s academic records (including class schedules, test scores, transcripts, attendance, etc.)
• UBMS staff to obtain documentation verifying my student’s U.S. citizenship, permanent resident status, or intent to become a permanent resident.