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

The U.S. Department of Education requires collection of the following data in order to determine student eligibility. Failure to provide the necessary supporting documents will disqualify your application from consideration.

The information you provide to the UBMS program is confidential and is protected by 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 student is in foster care or in the care of Division for Youth or other institution, the parental income information is not required. However, written verification of a student's status is required from 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 an important part of the selection process. In at least 250 words, please type your essay in the space provided below.

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 background have influenced you in 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 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 Pima Community College, Desert Vista Campus, UBMS program access to 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 information that may be necessary for participation in the program. I further authorize the staff of Pima Community College, Desert Vista Campus, UBMS program access to my student's college enrollment, retention, and completion information, as well as financial aid information from colleges and the federal government.

I further certify that I am aware that the provision of any false, fictitious, or fraudulent information or the omission of any material fact 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 3729-20 and 3810-3812).

The following consent shall be valid for the entire duration of my son/daughter's participation in UBMS program and until completion of a bachelor's degree, or for 6 years following graduation from high school.

I hereby grant permission for my son/daughter to participate in the Pima Community College, Desert Vista Campus, UBMS year-round programing. I also give my consent for the following:

• The high school staff and administration will grant access to the UBMS staff my student's academic records (class schedules, test scores, transcripts, attendance, etc.)
• For the UBMS staff to obtain documentation verifying an applicant's U.S. citizenship, or national permanent resident status, or of his or her intent to become a permanent resident.