West Virginia Higher Education Policy-UBMS 1-Application Form

INITIAL APPLICATION
Thank you for your interest in the West Virginia Upward Bound Math and Science (UBMS) Program! To determine your eligibility for the program, please answer ALL sections completely. Once eligibility is determined, you will need to complete the application packet. If you have questions, contact our main office at 304-414-5572 or connect with the UBMS on site coordinator during office hours at your school.
STUDENT INFORMATION
Name:*

First NameMiddle NameLast Name
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:
(999)999-9999
Student Cell Number:
(999)999-9999
Citizenship (Check One):

U.S. CitizenPermanent ResidentOther
Current Grade:

89101112
Current GPA:
Student ID #
Social Security #
999-99-9999
Date of Birth

MonthDayYear
MM-DD-YYYY
Ethnicity:

American Indian/AlaskaNative AsianBlack/African AmericanHispanic or LatinoWhite/CaucasianNative Hawaiian or Pacific Islander
After graduating from high school, I plan to enroll in:

CollegeCareer and Technical Education ProgramArmed ForcesUndecidedOther
Email Address:*
example@example.com
PARENT/GUARDIAN INFORMATION
Student Resides with:

Both ParentsSingle ParentParent and Stepparent FosterParent(s)/Legal Guardian(s)Other
Parent 1
Name:

First NameLast Name
Phone:
(999)999-9999
Email Address:
example@example.com
Highest Education Level Completed

High SchoolAssociate DegreeBachelor’s Degree
Parent 2
Name:

First NameLast Name
Phone:
(999)999-9999
Email Address:
example@example.com
Highest Education Level Completed

High SchoolAssociate DegreeBachelor’s Degree
INCOME ELIGIBILITY STATEMENT
FINANCIAL INFORMATION: Did you and your spouse file a federal income tax last year?

YesNo
If you are unsure of your income status or do not file federal taxes, please submit a signed letter stating that you do not file taxes, what your taxable household income is, and from what sources it is received.
Please indicate the family size number here:
Please Select your TAXABLE income (line 15 on the 1040):

$0 - $21,870$21,871 - $29,580$29,581 - $37,290$37,291 - $45,000$45,001 - $52,710$52,711 - $60,420$60,421 - $68,130$68,131 -$75,840
ACKNOWLEDGMENT OF STATEMENT
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 Upward Bound Math and Science Program 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
PROGRAM CONSENT
My/Our student, {main_name}, (student’s name) has my/our permission to participate in the West Virginia Upward Bound Math/Science (UBMS) Program (September-May) and the Summer Program (June-August).

Media Release: I/We give permission for {main_name} (student’s name) picture and or video to be taken in connection with the activities of the West Virginia Upward Bound Math/Science (UBMS) Program and its agencies to be used in newspapers, television, magazine articles and talk concerning the project.

Program Research Consent: I/We give permission and consent of my minor child to participate in any Upward Bound Program and/or TRIO Program research involving surveys, questionnaires, etc. I am aware that participation is voluntary and will have no detrimental effect on my child’s participation and relationship with Upward Bound and TRIO Programs.

I/We give consent to release information necessary for UBMS to collect enrollment data that may constitute confidential information, including student transcripts, attendance, free or reduced lunch eligibility, course completions, test scores, grade point averages, college admissions, and financial aid records, postsecondary grade reports, and transcripts, activity participation reports and other information deemed necessary for the UBMS to meet program implementation and reporting requirements.

I/We give consent for UBMS 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 UBMS will track secondary and postsecondary academic progress and admission status until they are no longer attending an institution of higher learning.
Name of Student

First NameLast Name
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Name of Parent/Guardian

First NameLast Name
Parent Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

INITIAL APPLICATION

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

INCOME ELIGIBILITY STATEMENT

ACKNOWLEDGMENT OF STATEMENT

PROGRAM CONSENT