Lyon College-UBMS-Application Form

Upward Bound Math-Science, Lyon College
www.lyon.edu/UBMS

A guardian must complete the application with the student.

Student’s Name:

First NameMiddle NameLast Name

Preferred First Name

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Cell:

(999)999-9999

Student Email:

(One that is checked regularly – not a school email address.)

Social Security No. (required to obtain transcript)

999-99-9999

Biological Sex:

Preferred Pronouns:

Ethnicity

High School:

Current Grade:

Is the student a U.S. Citizen?

Is the student currently:

Has the student ever been in another Federally-Funded College Access Program?

Specify:

(e.g. Talent Search, UB, EOC, etc.)

Parent/Guardian Name:

First NameLast Name

Relationship to Applicant:

Cell Phone:

(999)999-9999

Email:

example@example.com

Level(s) of Education Completed:

Student Currently lives with this person:

Occupation:

Parent/Guardian Name:

First NameLast Name

Relationship to Applicant:

Cell Phone:

(999)999-9999

Email:

example@example.com

Level(s) of Education Completed:

Student Currently lives with this person:

Occupation:

Math or Science Teacher Name:

First NameLast Name

Email:

example@example.com

1. Total Number of Individuals Living in Student’s Household (i.e. applicant, parents, siblings, etc.):

2. Select one of the following. If the second option is selected, provide combined taxable income.

Combined TAXABLE income: $

(1040 form line 15)

Sign and date below to confirm the financial information recorded in this section is accurate and complete.

Parent/Guardian Signature

Date:

mm-dd-yyyy

Post-Secondary Education Goals (Check ALL that apply.)

What is your ultimate career goal or dream job?

Hobbies, Clubs/Organizations, Sports, etc.

Why do you want to join UBMS?

The information provided above is accurate to the best of my knowledge. I understand that the goal of the Upward Bound Math-Science program is to help students prepare for college. I pledge that it is my desire to enroll in and complete college upon graduation from high school.

Student Signature

Date

mm-dd-yyyy

As the parent/legal guardian of the student applicant I verify that the information provided is accurate to best of my knowledge. I understand that the goal of the Upward Bound Math-Science program is to help prepare my child for college. It is my desire for my child to attend college after completing high school. I also authorize the Upward Bound Math-Science program to obtain and store records of my child’s official transcript, test scores, and other relevant academic information via TRIAND or their school district.

Parent/Guardian Signature

Date

mm-dd-yyyy

Lyon College UBMS Application

Parent or Legal Guardian Information (1)

Parent or Legal Guardian Information (2)

School Reference

Financial Information

Student Goals & Interests

Student Commitment

Parent/Guardian Commitment