University Of North Carolina-Wilmington-UBMS-Application Form

SEAHAWK UPWARD BOUND MATH AND SCIENCE PROGRAM APPLICATION
What is the Seahawk Upward Bound Math and Science Program?

The Seahawk Upward Bound Math and Science (UBMS) Program is a federally funded TRIO project at the University of North Carolina Wilmington, offered in partnership with New Hanover and Brunswick County Schools. UBMS helps students strengthen their math and science skills, explore STEM careers, and prepare for college success through academic enrichment, hands-on learning, and financial literacy education.

What kind of services does UBMS provide?

UBMS is required to offer the following FREE services to qualifying students:
- Academic Tutoring
- College and Career Exploration
- Financial Literacy
- College Entrance and Financial Aid Applications Assistance
- SAT/ACT Preparation
- University Campus Tours
- Academic Advising
- Saturday Academy
- Summer Enrichment
- Academic and Cultural Exposure
What are the eligibility requirements?

The Seahawk Upward Bound Math and Science (UBMS) Program is open to U.S. citizens and permanent residents enrolled in high schools in the New Hanover or Brunswick Counties of North Carolina. Applicants should have a 2.5 GPA or higher, or, if no GPA is available, eligibility will be determined using their most recent report card. Students must also meet at least one of the following criteria:

a) Be a potential first-generation college student (neither parent has earned a bachelor's degree); and/or

b) Have a taxable income within the federal low-income guidelines

Part B: To Be Completed by Parent or Guardian
Parent/Guardian 1
Parent/Guardian 1 Name:*

First NameLast Name
Parent/Guardian 1 Cell Phone:*
(999)999-9999
Parent/Guardian 1 Home Phone:
(999)999-9999
Parent/Guardian 1 Email Address:*
example@example.com
Relationship to Student:*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 Highest Level of Education:*
Parent/Guardian 1 Signature:*

Clear
Name of Parent/Guardian Signing:*

First NameLast Name
Date:*

MonthDayYear
mm-dd-yyyy
Parent/Guardian 2
Parent/Guardian 2 Name:

First NameLast Name
Parent/Guardian 2 Cell Phone:
(999)999-9999
Parent/Guardian 2 Home Phone:
(999)999-9999
Parent/Guardian 2 Email Address:
example@example.com
Relationship to Student:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Highest Level of Education:*

Part D: Release and Liability Forms
School Records Release Form
The information requested on this form will be utilized to assist us in providing services for your child. To provide the most effective services, we may need to obtain information from several sources such as your child’s school of enrollment, testing agencies, counselors, social workers, etc. ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT.

As a parent and/or legal guardian, I grant the Seahawk Upward Bound Math and Science Program permission to obtain school records and test results from the secondary school my child is attending.

I will also permit the Seahawk Upward Bound Math and Science Program staff to speak with teachers, counselors, and other school administrators at my child’s school to obtain and exchange information as part of the services my child will receive from the Seahawk Upward Bound Math and Science Program.

I authorize the Seahawk Upward Bound Math and Science Program to access or release copies of my child’s progress reports and/or standardized test results that are necessary to assist my son/daughter in achieving his/her educational goals.
Parent/Guardian Signature*

Clear
Parent/Guardian Name *

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
WAIVER OF LIABILITY

As parent and/or legal guardian, I authorize and permit my child to participate in field trips, activities, and events offered by the Seahawk Upward Bound Math and Science Program. I understand that my child may be leaving his/her school campus or the University of North Carolina Wilmington and may be transported by the Seahawk Upward Bound Math and Science Program staff at the University of North Carolina Wilmington. I agree that the University of North Carolina Wilmington, the Seahawk Upward Bound Math and Science Program, the New Hanover and Brunswick County School Systems, the school my child is attending, and anyone associated with the University of North Carolina Wilmington will not be held liable for any loss, injury, or death related to any field trips or events.

Further, I agree to hold the University of North Carolina Wilmington, the Seahawk Upward Bound Math and Science Program, Advisory Committee members, officers, staff, volunteers, the New Hanover and Brunswick County School Systems, and the school my child is attending harmless from any claims whatsoever occasioned in any of the situations to which I have agreed. The Seahawk Upward Bound Math and Science Program at the University of North Carolina Wilmington shall not be held liable for any claims whatsoever occasioned in any of the aforementioned situations to which I have indicated agreement.
Parent/Guardian Signature*

Clear
Parent/Guardian Name *

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
MEDIA RELEASE

Periodically, students participating in the Seahawk Upward Bound Math and Science Program events may be photographed, filmed, or interviewed. As the parent and/or legal guardian, I grant permission for my child to participate in photographs, films, social media, or interviews as they pertain to the Seahawk Upward Bound Math and Science Program. I also understand that such pictures, films, social media, or interviews may be used to promote or publicize the Seahawk Upward Bound Math and Science Program events or demonstrate how federal funds are being used to assist students.
Parent/Guardian Signature*

Clear
Parent/Guardian Name *

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Part E: Recommendation Form
Please notify your school counselor that you are applying to the Seahawk Upward Bound Math and Science Program. They will be contacted, via email, to complete the necessary recommendation form.
School Counselor Recommendation
Your School Counselor's Name*

First NameLast Name
School Counselor’s Email Address*
example@example.com
School Counselor’s School Phone Number
(999)999-9999

SEAHAWK UPWARD BOUND MATH AND SCIENCE PROGRAM APPLICATION

Parent/Guardian 1

Parent/Guardian 2

School Records Release Form

School Counselor Recommendation