Jackson State University-Conquerors-UBMS-Application Form

Conquerors Upward Bound Math & Science Program Student Application
Dear Applicant:

Thank you for your interest in the Jackson State University Conquerors Upward Bound Math & Science Program. Upward Bound Math & Science is a free college preparatory program for high school students funded by the U.S. Department of Education and sponsored locally by Jackson State University. Upward Bound Math & Science is designed to provide participants the skills and motivation necessary to navigate and complete a program of secondary education and to enter and succeed in a program of post-secondary education.

Upward Bound Math & Science is a year-round program. The program provides tutorial services, classes, and special events during the school year to strengthen academic skills and prepare students for success at the college level. The program also provides academic advising and individual assistance with the college admissions and financial aid application process during the academic school year. Our six-week summer academic component is designed to simulate a college-going experience that includes daily coursework in math, laboratory science, composition, literature, foreign language as well as cultural, social, and recreational events and activities.

Eligibility to participate in the program is determined individually. Each applicant must meet basic eligibility requirements set forth by the U.S. Department of Education, that require neither parent to have a four-year college degree and family income verification. Our program services 60 students from Jim Hill, Lanier, and Provine High Schools. Therefore, it is important that you complete your application as soon as possible. When space is not available, an application will be placed on our waitlist for later consideration.

All completed applications will be reviewed and eligible applicants contacted for a student and parent interview with program staff.

Thank you for your interest in the JSU Conquerors Upward Bound Math & Science Program. Please call a staff member at (601) 979-0223 if you have any questions or need assistance.

Who is Eligible to Participate in the Program?
- Are currently enrolled at Jim Hill, Lanier, and Provine High Schools
- At least 13 years of age but not older than 19
- U.S. citizen or permanent resident
- First-Generation (a student whose parent did not complete a 4-year college or university degree)
- Meet the low-income requirements as defined by the Federal Government
- An individual who has a high risk for academic failure
Free Services Offered by the Upward Bound Math & Science Program
- Preparation of Educational Plans
- Academic Advisement
- Career Exploration
- Information on Post-Secondary Education
- Financial Aid (FAFSA) Assistance
- American College Test (ACT) Prep
- Tutoring (FREE)
- College Campus Tours
- Cultural Enrichment Activities
- Six-Week Summer Camp Program
Demetri Jones

Director

Conquerors Upward Bound Math & Science

Office: (601) 979-4074

Email: conquerorsubms@jsums.edu

Instructions for completing this form:

1. Read each question carefully and complete all sections by writing in black or blue ink or typing on the computer.

2. If you fail to answer all necessary questions and/or omit signatures, your application will be returned to you for completion.

3. Students cannot participate in program activities until all application materials are complete and returned to the address above.

4. If you are under the age of 19, you and your parent or guardian must sign all application materials.

***The information you provide on this application will be secure and confidential***
Student Name: *

First NameMiddle InitialLast Name
Contact Information: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email*
example@example.com
Parent/Guardian Email*
example@example.com
Home Phone
(999)999-9999
Student Cell Phone*
(999)999-9999
Parent/Guardian Cell Phone*
(999)999-9999
Parent/Guardian Work Phone
(999)999-9999
Birthdate*

MonthDayYear
Date
Age*
Social Security Number*
999-99-9999
Gender (please check)*

FemaleMale
Do you identify as Hispanic or Latino? (please check)*

YesNo
Which of these ethnicities do you identify with? (please check all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteTwo or More Races
Name of school currently attending: *
Other School
Current Grade:*
Current Grade*
Name of school attending next academic year:*
Name of school attending next academic year:*
Student ID:*
Grade Point Average: *
Expected Graduation Date:*
Upon graduation from high school, what are your plans? (please check)*

4-Year University/College Program2-year College ProgramMilitaryBecome EmployedTechnical/Vocational/Trade ProgramNot Sure
Are you a member of another TRIO program (Hinds Community College, Jackson State University or Tougaloo College)? (please check)*

Upward BoundUpward Bound Math/ScienceTalent SearchEducational Opportunity CentersNone
Do you have a relative or friend that is a member of a TRIO Program?*

YesNo
If Yes
Are you a U.S. Citizen? (please check):*

YesNo
Are you a permanent resident of a U.S. territory or have you applied/intend to apply for U.S. citizenship?*

YesNo
If yes, what is your Alien Registration Number (USCIS number)
Disconnected Youth/At Risk Students: “Disconnected Youth” is defined as individuals between the ages of 14 and 24 who are homeless, in foster care, involved in the juvenile system, or neither employed nor enrolled in and educational institution. Are you a disconnected youth? (please check):*

YesNo
Parent/Guardian Information:
Parent/Guardian Name:*

First NameLast Name
Relationship to Student*
Marital Status (circle one):*

SingleMarriedDivorcedWidowSeparated

School Record Release, Waiver to Provide Services, and Post-High School Tracking Release
By signing here, I understand that as a part of the Jackson State University Conquerors Upward Bound Math & Science Program selection process, my child’s school records including transcripts, progress reports, standardized test scores, attendance records, disciplinary actions, evaluations, and medical records will be examined. I also understand that if my child is selected for the Jackson State University Conquerors Upward Bound Math & Science Program, the Upward Bound Math & Science Program will continue to require this information from my child’s high school and college. This information is necessary to track the performance of the Program’s participants and graduates. I hereby give permission for Jackson State University Conquerors Upward Bound Math & Science Program to request the above information from my child’s high school and future colleges that he/she may attend.
Student Name:*

First NameLast Name
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Certification of Application and Information Release

I (We) certify that the information provided on the application is true and correct to the best of my (our) knowledge; I (We) further understand that the completion of this application does not guarantee acceptance into the JSU Conquerors Upward Bound Math & Science Program. I (We) also authorize the use of my (our) image and name in JSU Conquerors Upward Bound Math & Science publications, editorials, advertisements, and media releases to the program and its affiliates organizations. My (Our) consent will remain in effect until I (We) revoke this authorization, in writing, with the JSU Conquerors Upward Bound Math & Science office.
Student Name:*

First NameLast Name
Student Signature:*

Clear
Date:*

MonthDayYear
Date
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date

Applicant Essays
Both essays must be completed by the applicant with a minimum of five (5) sentences.
Please explain why you want to participate in the Jackson State University Conquerors Upward Bound Math & Science Program*
Upward Bound is committed to helping students get into college and complete a degree to become successful in a career of their choice. What is your intended major or career? Why? *
Are you interested in pursuing a career in the fields of math or science?*

YesNoN/A

Conquerors Upward Bound Math & Science Program Student Application