Murray State University-UBMS-AIMS-I-2023 Application Form

UPWARD BOUND MATH AND SCIENCE APPLICATION

Academic Year 2023 - 2024
In order to be considered for program participation in Upward Bound Math and Science, please be sure to:
- Complete each section of the application
- Provide student signatures where requested
- Provide parent/guardian signatures where requested
- Complete all writing prompts
- Provide teacher names for letters of recommendation
- Transcripts, test scores, current grades, absences, and discipline reports will be requested from your school.
Once all materials are received by Upward Bound Math and Science staff, your application package will be reviewed; and you will be notified about acceptance into the Upward Bound Math and Science program.

Upward Bound Math and Science is a U. S. Department of Education-funded program: $324,979 per year
PART A: STUDENT INFORMATION

Please complete each question in this section based upon the student's current status.
Student Email Address*
example@example.com
Student Cell Phone Number*
(999)999-9999
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*

FemaleMaleNon-binary
Preferred Pronouns

She/Her/HersHe/Him/HisThey/Them/Their
Current Grade Level*
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race (Ethnicity)*

Native American/Alaskan NativeAsianAfrican American or BlackCaucasian or WhiteNative Hawaiian or IslanderHispanicTwo or more Races
Citizenship Status (Select One):*

I am a U.S. citizen or national or a permanent resident of the United States.I am in the United States for other than a temporary purpose and can provide evidence from the Immigration and Naturalization Service of my intent to become a permanent resident.I am a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands.I am a resident of the Freely Associated States - the Federated State of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau.
PART B: GUARDIAN AND FAMILY INFORMATION

Please complete all sections that apply
Parent/Guardian 1
Name*

First NameLast Name
Phone Number*
(999)999-9999
Relationship to Applicant*
Earned a Four-Year College Degree*

YESNO
Applicant Currently Lives with This Person*

YESNO
Parent/Guardian 2
Name

First NameLast Name
Phone Number
(999)999-9999
Relationship to Applicant
Earned a Four-Year College Degree

YESNO
Applicant Currently Lives with This Person

YesNo
Is the applicant in a foster care program?*

YesNo
Does the applicant have a court-appointed guardian?*

YesNo
Does the applicant currently receive free or reduced lunch at school?*

FreeReducedNo
Family Taxable Income
If you are unsure of your income status or do not file federal taxes, you may submit a signed United States Income Tax Return or other government documents that verify family income.

To determine your taxable income, refer to your 2021 federal tax return:

Line 6 on 1040 EZ
Line 27 on 1040A
Line 43 on 1040
Size of Family Unit*
Taxable Income Less Than (effective January 12, 2022, until further notice)*

Less than $21,870Less than $29,580Less than $37,290Less than $45,000Less than $52,710Less than $60,420Less than $68,130Less than $75,840More than $75,840
The current definition of “homeless” for this program is:
- Lack a fixed, regular, and adequate nighttime residence.
- Primary nighttime residence is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for humans.
- Share the housing of other persons due to loss of housing, economic hardship, or similar reason.
- Currently living in a motel, hotel, trailer park, or campground due to lack of alternative, adequate accommodations.
- Currently living in an emergency or transitional shelter.
- Currently living in car, park, public space, abandoned building, substandard housing, bus or train station, or similar setting.
Using the criteria above, are you considered homeless?*

YesNo
PART C: ACKNOWLEDGEMENT AND SIGNATURES
I verify, by signing this document, that the information provided is accurate to the best of my knowledge. I understand that this information will be held in complete confidence by the TRIO programs at Murray State University and by the U.S. Department of Education.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
PART D: PERSONAL AND SCHOLASTIC INFORMATION

It is important that you, the student, complete every section of Part D.
High School*
Educational Interests After High School*

4-year College2-year CollegeVocational/Technical CollegeCertificationMilitary
Career Choice #1*
Career Choice 2*
Career Choice 3
Career Choice 4
Check Any of the Following TRIO Programs in Which You Already Participate*

TRIO Upward BoundTRIO Talent SearchTRIO Upward Bound Math and ScienceI do not participate in any TRIO programs
Tell us about yourself: Extracurricular Activities, Community Service, Awards, Honors, Interests, and Hobbies*
Tell us how UBMS can help you meet your goals for becoming what you want to be.*
Is there anything else you would like to share with us? We would love to know more about you.

Do you have any of the following technologies?

	YES	NO
Desktop Computer
Laptop Computer
iPad or Tablet
Internet Connection
Smart Phone

PART E: RECOMMENDATION REQUESTS

Please list the name and school for each of the following. Please choose teachers that know you well enough to provide a complete recommendation.
Science Teacher
Name*

First NameLast Name
School*
Email address*
example@example.com
Math Teacher
Name*

First NameLast Name
School*
Email address*
example@example.com
PART F: STUDENT INFORMATION RELEASE FORM
MURRAY STATE UNIVERSITY
UPWARD BOUND MATH AND SCIENCE

The information you provide to the Upward Bound Math and Science Program and/or Murray State University is for UBMS, Murray State University, and the U.S. Department of Education use only. The information provided in this application is necessary to determine eligibility for the program and may be used for research purposes. Only UBMS, Murray State University personnel, and U.S. Department of Education personnel have access to these records. I give consent to release the following information to the Murray State University Upward Bound Math and Science Program as requested:
- Standardized Test Results (ACT, SAT, CTBS, PSAT, etc.)
- High School Grade Reports
- High School Transcripts
- College Admission and Financial/Aid Records
- College Grade Reports and Transcripts
Further, I give consent for UBMS/Murray State University 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 AIMS will track my child’s academic progress and admission status until he/she is no longer attending an institution of higher learning.

I give consent for UBMS/Murray State University to use photographs of my child for news releases, publicity, and other information about the program released to the public.

I give consent for this release to remain in effect until my child’s completion of college and/or post-graduate work is completed, if selected as an UBMS Program participant. If not selected for the Program, I give consent for the information provided in this application and information released as described above to be used by UBMS for research projects.
Name of Student*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
PART G: PERMISSION AND RELEASE FORM
I/we hereby give my/our consent for my child to attend Upward Bound Math and Science sponsored activities at Murray State University. These activities may include field trips, cultural events, and workshops. I /we understand my/our child will be provided transportation to and from these events and hereby agree to same. As parent (s) or the natural guardian (s) of the above named student, I/we release Murray State University, its Board of Regents and individual Regents, directors, officers, agents, and employees, the Director of Upward Bound Math and Science and any staff member of Upward Bound Math and Science (hereinafter referred to as “released parties”) from any and all liability for injury to the above named child, including death, which may arise from any causal factor, including negligence. In the event my/our under-age child should subsequently bring legal action and obtain judgment against the released parties, or any of them, I/we hereby bind and obligate myself/ourselves to indemnify said released parties up to and including the full amount of the judgement.

Furthermore, I/we understand that I/we forever release the released parties from all claims, damages, actions, or causes of actions which may occur due to any decisions made with respect to the medical care or treatment of my/our child. I/we further authorize agents of the Upward Bound Math and Science Program and/or employees/agents of Murray State University to authorize emergency medical treatment for my/our child in the event that I/we are unavailable to provide such consent and hereby agree to hold said released parties harmless as to any and all decisions in regard to said medical care.

This release is unlimited in duration, and applies to any and all Upward Bound Math and Science-sponsored activities in which the above-named individual participates.

This permission and release form is entered into voluntarily and of my/our own free will and volition. I/we further understand and agree that this agreement is intended to be as broad and inclusive as is permitted by Kentucky law, and that if any portion of this agreement is held invalid, the balance shall continue in full legal force and effect. My/our signature(s) indicate(s) that the above-named child resides in my/our home, and I/we are the custodial parent(s)/guardian(s) of said child.
Student Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Parent Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
PART H: COMMITMENT CONTRACT
The partnership between Upward Bound Math and Science at Murray State University and its students, parents, and school liaisons is unique and dependent upon shared responsibilities. It is critical that everyone works together to provide a structured plan for student success in the program. Please read the following commitments carefully, as your signature below will indicate your full support of the Upward Bound Math and Science program.

STUDENT COMMITMENT

I AGREE TO:
1. Attend high school (scheduled classes, labs, and required testing) regularly.
2. Enroll in an academically rigorous schedule of courses that meet college entrance requirements.
3. Attend monthly school meetings and two weekend program workshops per semester, in order to participate in the Summer Component of the program.
4. Display behavior and attitudes that are respectful, appropriate, and bring credit to myself, my family, my high school, Upward Bound Math and Science, and Murray State University.
5. Attend at least one Summer Program Component to be eligible to participate in the Bridge Component of the program.
  Students who neglect their responsibilities to UBMS by failing to comply with the conditions listed above may be dismissed from the program.
PARENT/GUARDIAN COMMITMENT

I AGREE TO:
1. Grant permission for my child to participate in the Upward Bound Math and Science program.
2. Fully support and facilitate my child’s involvement in the Upward Bound Math and Science program.
3. Attend Upward Bound Math and Science program activities involving parents/guardians during the Academic and Summer Components of the program.
UPWARD BOUND MATH AND SCIENCE STAFF COMMITMENT

WE AGREE TO:
1. Meet with each student on a regular basis, provide information, tutoring, and activities that will help him/her to achieve his/her full potential.
2. Seek parental involvement in Upward Bound Math and Science program activities.
3. Work closely with parents/guardians and school personnel to ensure that each student is receiving the best combination of services.
ACADEMIC PROBATION AND DISMISSAL POLICY SUMMARY

Reasons for probation may include, but are not limited to, the following:
1. A student does not maintain a GPA of 2.50 or higher after two (2) quarters. Interventions such as tutoring and mentoring may be required.
2. A student does not participate in at least two workshops per semester without pre-arranged notice with program staff.
3. A student shows a lack of initiative in completing assignments or responsibilities, including regular attendance (at school or in the program).
4. A student displays a willful disregard for program guidelines.
5. A student demonstrates disruptive behavior with peers or staff.
DISMISSAL:

Because of the extensive resources invested in each student, the Upward Bound Math and Science Program cannot afford to support students who are not serious about academic improvement or pursuing higher education. Failure to comply with the above guidelines will result in dismissal from the program.

We have read the commitments and the “Academic Probation and Dismissal Policy” above and we agree to adhere to the conditions set forth.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Coordinator Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Program Director Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

UPWARD BOUND MATH AND SCIENCE APPLICATION

PART A: STUDENT INFORMATION

PART B: GUARDIAN AND FAMILY INFORMATION

PART C: ACKNOWLEDGEMENT AND SIGNATURES

PART D: PERSONAL AND SCHOLASTIC INFORMATION

PART E: RECOMMENDATION REQUESTS

PART F: STUDENT INFORMATION RELEASE FORM

PART G: PERMISSION AND RELEASE FORM

PART H: COMMITMENT CONTRACT