Upward Bound Math & Science Program

Upward Bound Math & Science Program A College-Prep Program sponsored by Northern Arizona University New for Program Year 2015-2016 Students participate year-round each year beginning in 2016 January May Participate in monthly college-prep services & complete assignments June 4 July 3 Study and live on Northern Arizona University campus September December Participate in monthly college prep services & complete assignments Qualifications To qualify for the UBMS program interested students must: Be a Freshman or Sophomore student in high school Have a 2.5 minimum GPA Attend high school at: - Coconino - Many Farms - Greyhills Academy - Monument Valley - Holbrook - Tuba City Have passed high school algebra by June 2016 Have passed one high school science course by June 2016 Student s family meets federal low-income guidelines OR student is first generation college-bound (student s parents have not received a bachelor s degree) Interested students must submit their applications via email, fax, or postmarked by the January 8, 2016 deadline. For additional copies of this application please photocopy or download from our website: NAU.EDU/UBMS

Upward Bound Math & Science Program A College-Prep Program sponsored by Northern Arizona University About the Upward Bound Math & Science (UBMS) Program What is the UBMS Program? The UBMS Program is a year-round college-prep academic outreach program. Students participate from their high schools during the academic year. Participants who perform well are invited to apply to the summer component of the program to take classes and live on the Northern Arizona University (NAU) campus for four weeks. Our goal is to insure that UBMS participants have every opportunity to continue their education past high school and are successful once they are at their post-secondary institution. What level of commitment will be expected of an interested student? Students considering UBMS need to know that participating in this program requires extensive commitment and perseverance year-round. Students are expected to participate from the time they are accepted into the program until they graduate from high school. What are some of the benefits? The UBMS Program offers many opportunities for its participants. Access to Arizona Scholarships for students participating in outreach programs Written recommendations for scholarships Additional support in Math, Science and English courses Free room and board, classroom supplies, access to the NAU Health and Learning Center, and activities in the evening and on weekends during the summer component Who provides summer transportation to and from the program? Parents will need to provide transportation to and from Flagstaff, in the form of three round trips for the summer component of the program: check-in/orientation day, a mid-program youth symposium/weekend break, and the graduation ceremony for all participants on the last day of the program. Each year parents enjoy participating with their students in the youth symposium and celebrating their summer accomplishments at the graduation ceremony. 2

Upward Bound Math & Science Program A College-Prep Program sponsored by Northern Arizona University 2015-2016 New Checklist Application Deadline January 8, 2016 Before you go home today sign the High School Transcript Request Form (page 4) and give it to your High School Registrar. Ask him/her to e-mail or fax your transcript to Laurie Balenquah. Then make an appointment with your Counselor, Science or Math teacher to ask him/her to complete and return the Recommendation Form (page 5). Tonight tell your parent(s)/guardian(s) that you are interested in the UBMS Program. Show them the application and ask one of your parents/guardians with whom you live with to help you complete pages 9-14. Make sure to agree on a date and a time for you to work on the application together. Tomorrow meet with your English teacher to inform them of the essay requirements found on page 6. Request assistance with editing and set a deadline to give your essay to him/her. Again make sure to agree on the date with your teacher, as well a date for you to collect the edited essay. After turning in your essay, take time to write a thank you note to your English teacher for their help. Complete the Student Information, the High School Information, and proof of citizenship forms (page 7-8). Then make sure to sign page 13. Gather all the pages of your application and review them to verify all blanks are completed, especially all the pages that require signatures. Finally agree on a date and time with your parent/guardian or high school counselor to mail, e-mail, or fax your application BEFORE the January 8 deadline. Depending on how you are submitting your applications send it by: Scanning all pages and attaching to an email addressed to UBMS@nau.edu Faxing the application to UBMS Fax: Attention UBMS at (928)523-9466 An envelope addressed to UBMS c/o Laurie Balenquah, P.O. Box 6035, Flagstaff. AZ 86011 Hand delivery to the UBMS Office. Please make sure to call ahead to (928)523-1315, (928)523-1315 or (928)523-2597 for parking information and office location. After submitting your application you can obtain verification by e-mailing or calling (928)523-1351 or (928)523-1315 to confirm each page was received by the deadline and is complete. If items are missing a UBMS staff member will contact you using the information provided. 3

2015-2016 A College-Prep Program sponsored by Northern Arizona University Freshman and Sophomore Applicants: Instructions: Read and sign the request form. Submit it to your High School Registrar with assistance from your counselor. Upward Bound Math & Science High School Transcript Request Form Registrar: Please E-mail or Fax with official transcript to follow High School Transcript: Freshman applicants: please send current courses without grades Sophomore applicants: please send current courses without grades, in addition to 2014-2015 high school grades. Deadline January 8, 2016 Fax: Attention Laurie Balenquah at (928)523-9466 Email: Laurie.Balenquah@nau.edu Student s Full Name (Please Print) Date of Birth Student s Signature 4

Upward Bound Math & Science Program A College-Prep Program sponsored by Northern Arizona University Counselor/Science/Math Teacher Recommendation Form PART I - to be completed by applicant Applicant Name Grade Level Current Course Grade PART II to be completed by the current Counselor or Instructor Place an x in the appropriate column of each characteristic listed that best describes the applicant. STUDENT CHARACTERISTICS EXCELLENT AVERAGE FAIR POOR Academic Performance Conduct in Class Willingly Participate in Class Respects Others and Their Property Ability to Follow Instructions Completes Assigned Work on Time Study Skills/Habits Analytical Thinking Skills Maturity/Integrity Punctuality Eager to Learn New Things/Initiative Demonstrates Motivation to Complete a 4-Week Summer Program Please provide comments on motivation, behavior, personality, strengths or weakness that you feel are pertinent to the student s performance in the Upward Bound Math and Science Program. If the student fails to satisfy some academic requirements, please explain in detail. Additional comments may be written on the back. Length of time you have known the student: Recommender s Signature Date School Telephone Number Please return this form to: Upward Bound Math & Science PO Box 6035 Flagstaff, AZ 86011 FAX: Attention Laurie Balenquah (928)523-9466 5

2015-2016 A College-Prep Program sponsored by Northern Arizona University Personal Essay Write an essay including at least one paragraph about each of the following topics. Your essay should be at least five paragraphs in length and should be typed using double spaced 12 point font. Please put your name and date including year at the top of each page. 1. Introduce yourself and tell us about your family 2. Are you interested in math? Are you interested in science? What careers are you interested in at this point in your life? What are your academic goals for during and after high school? Do you want to go to college? How far do you think you will take your education? Tell us why. 3. How do you plan to reach these goals? For example, what are you doing now and what will you do in the future to reach your academic goals? How will attending a math and science program help you reach your goals? 4. What motivates you to pursue a college degree after you graduate from high school? 5. If you have received a grade of a D or an F in ANY high school course(s), please include an additional paragraph in your essay and explain why you received each of the low grade(s) and when you plan to retake the course(s). Essay Style Tips Although you must write your own essay, we recommend you have an English teacher edit a draft. Paragraphs include: introduction, support, and conclusion Main ideas and opinions supported with specific examples from your life. Proofread carefully correcting all grammar, spelling, capitalization, and punctuation errors. Include a relevant title for your essay and ensure your full name is on every page. 6

You must complete the entire application thoroughly and leave no blank spaces. Please print or type. Student Applicant Information APPLICANT NAME : Last First Middle Initial PERMANENT ADDRESS: Street / Box Number City/Town State ZipCode HOME PHONE: ( ) CELL PHONE: ( ) MESSAGE PHONE: ( ) EMAIL: How often do you check email? ( ) Daily ( ) Weekly ( ) Monthly Needed for federal funding purposes CHECK ONE: Female ( ) Male ( ) SOC.SEC.NO.: - - D.O.B.: ETHNICITY (check all that apply): ( ) White ( ) Asian ( ) Hispanic or Latino ( ) Black or African American ( ) American Indian/Alaskan Native Tribal Affiliation: ( ) Native Hawaiian or Pacific Islander ( ) Other (please list): High School Information HIGH SCHOOL NAME: HIGH SCHOOL PHONE: STREET ADDRESS: CITY/STATE: ZIP: HIGH SCHOOL FAX: COUNSELOR S NAME: COUNSELOR S EMAIL: 7

Student Applicant s Name: Date: High School Information Continued Current Class Status: ( ) Freshman ( ) Sophomore Expected year of graduation: I have completed Algebra-1: ( ) Yes ( ) No Title of course completed: Current Math Class: Teacher s Name: I have completed at least one high school science class: ( ) Yes ( ) No Current Science Class: Teacher s Name: Are you in Talent Search? ( ) Yes ( ) No Talent Search Advisor: Are you in Upward Bound? ( ) Yes ( ) No If yes, are you willing to quit regular Upward Bound/Talent Search permanently to participate in the UMBS Program? You cannot be in two TRIO funded programs. ( ) Yes ( ) No You understand that if at any time during your participation in UBMS you transfer to a non-target school, you will no longer be eligible for UBMS and will need to seek other TRIO programs affiliated with your new school. ( ) Yes ( ) No Proof of Citizenship and Residency or Applicant ( ) United States Citizen ( ) Permanent Resident of the United States (Immigrated to the U.S. Applied and achieved permanent residency. Please attach copy of documentation.) ( ) Intending to become a United States resident (Please attach Immigration and Naturalization Service documentation of intent to establish permanent residency.) ( ) Other (please explain) All students are required to SUBMIT DOCUMENTATION of their legal residency of the United States. Native American Applicants submit: Bureau of Indian Affairs Card Number, Tribal Treaty Card Number, or Tribal Enrollment Number. All other applicants submit a COPY of one of the following: Birth Certificate showing applicant was born in the United States, U.S. passport (current or expired), or Immigration and Naturalization Service documentation of intent to establish permanent residency. 8

Student Applicant s Name: Date: Parent/Guardian Information MOTHER/LEGAL GUARDIAN: Last First ADDRESS: Street/Box City/Town State Zip EMAIL ADDRESS: HOME PHONE: ( ) CELL PHONE: ( ) WORK PHONE: ( ) FATHER/LEGAL GUARDIAN: Last First ADDRESS: Street/Box City/Town State Zip EMAIL ADDRESS: HOME PHONE: ( ) CELL PHONE: ( ) WORK PHONE: ( ) PARENTAL STATUS: ( ) Parents live together ( ) Parents are separated/divorced ( ) Father deceased ( ) Mother deceased ( ) Both parents deceased WITH WHOM DOES APPLICANT LIVE? ( ) Mother/Father ( ) Mother/Stepfather ( ) Father/Stepmother ( ) Mother Only ( ) Father Only ( ) Other please list the names of adults who provide care to the applicant and the relationship of each caregiver to the applicant (i.e. Legal Guardian, Foster Parent, Relative etc.) If more space is needed please write on the back of this form. SUPPORT FROM PARENTS: If participant does not live with both of their natural or adoptive parents, have they received financial support from the other parent? ( ) Yes ( ) No ( ) Not Applicable 9

Student Applicant s Name: Date: Parent/Guardian Questionnaire Thank you for encouraging your child to apply to the UBMS Program. Please consider the following questions and answer each question honestly and as detailed as possible. Attach additional sheets if necessary. PARENT S NAME: 1. What do you see as the applicant s strengths? (academic, personal, social) 2. Where do you see the applicant needing to improve? How do you see a math and science program benefiting them? 3. Have you spoken with the applicant about what he/she will do after high school? If you have, what are his/her plans? 4. How often is the applicant absent from class? (never, rarely, often) 5. What average grade does the applicant generally earn in each semester? Choose One: A B C D F 10

Student Applicant s Name: Date: Parent Income Affidavit 2014 Tax Year Information Method of filing income tax (please check one): ( ) Married, filing jointly ( ) Married, filing separately ( ) Head of household ( ) Other (explain): Head of Household: We need to calculate your standard deduction, please check all for which you qualify You: ( ) 65 or older ( ) Blind Spouse: ( ) 65 or older ( ) Blind Total number of people supported by head of household (include head of household): Income Affidavit Instructions If you are married, filing jointly, please include your spouse s income. Please give your yearly income. SOURCES OF INCOME (Enter a dollar amount in every box. Enter a zero in each category where no income was earned). Mother/Guardian Father/Guardian NAME: (Please print) Social Security Number Amount from Employment (Yearly) $ $ Alimony (Yearly) $ $ Social Security (Yearly) $ $ Unemployment (Yearly) $ $ TANF (Yearly) $ $ *State all other sources of income below (attach an additional sheet if necessary). Source 1 $ $ Source 2 $ $ 11

Student Applicant s Name: Date: Parent Income Affidavit Continued Foster Parents Only Check here if applicant is in foster care ( ) Amount of monthly payment: First Generation Information Has the student applicant s natural (or adoptive) Mother graduated from a four year college? ( ) Yes ( ) No Has the student applicant s natural (or adoptive) Father graduated from a four year college? ( ) Yes ( ) No Household Information On the following chart please list ALL members of the household in which you live, including the student applicant and those who are claimed for tax purposes. Attach an additional sheet if necessary Name Age Relationship to student Highest Grade Completed (*Use grade levels below) Occupation *Grade levels Total number in your household that are claimed for tax purposes A No formal education D High School (9 th -12 th ) GED G Associate Degree B Elementary (K-6 th ) E Some college credit, but no degree H Bachelor s Degree C Jr. High School F Vocational or technical training 12

Student Applicant s Name: Date: Parent Income Affidavit Cont. Certification: All of the information on this application is true and correct to the best of our knowledge. If asked by an authorized official, we agree to give proof of the information that we have given on this application. We also realize that purposely giving false or misleading information on this application may result in a $ 10,000 fine, a prison sentence, or both [PL99-498 Sec. 490 (a.-d.)]. The Upward Bound Math and Science Program at Northern Arizona University is required by federal law to report cases of suspected fraud to appropriate law enforcement agencies for investigation. Parental/Guardian Consent: I give my permission to any and all public assistance programs to release the necessary information to verify the above income (i.e., Social Security Benefits Programs, Food Stamps, School Lunch Programs, and/or Welfare/General Assistance Programs). Mother/Legal Guardian: Printed Name Signature: Date: Father/Legal Guardian: Printed Name Signature: Date: Student Signature How did you hear about this program? By signing below, I authorize that all of the information provided in this application is correct and true to the best of my knowledge. Printed Name: Signature: Date: 13

Student Applicant s Name: Date: Copy of Applicant s Government Issued Photo ID Each UBMS applicant must either submit a copy of the applicant s government issued photo ID or sign the statement below to defer to the date that the student will be able to submit a copy of the photo ID. Check the box below that best fits the current applicant s status. OR Attached is a copy of my Government Issued Photo ID that is valid through 07/02/2016 Important Note: High School IDs are not acceptable for this purpose. Acceptable forms of current and valid IDs are either a: State Photo ID issued by the Arizona Motor Vehicle Division (MVD) U.S. Passport Complete and submit this page with the application. I will obtain an ID from the MVD by (please write in a date, no later than January 8, 2016) and fax a copy of the ID by (please write the same date). If the photo ID is not immediately available on the date the student applies for the ID inquire about the number of days the student will need to wait to obtain the ID. Then contact Laurie Balenquah to revise the deadline to fax this page of the application. Upon receiving receipt of the ID fax a copy with the attention to Laurie Balenquah to (928)523-9466. Applications will be reviewed with this information. If the applicant has not submitted a copy of a government issued photo ID by the date stated above his/her applications will be considered incomplete. If necessary, communicate with Laurie to revise the date above with a valid explanation. Use the information below to assist the student applicant with obtaining the required ID and submitting it to the UBMS Office. Printed Parent/Guardian Name Parent/Guardian Signature Date Printed Parent/Guardian Name Parent/Guardian Signature Date Prepare for your visit to the MVD office, the student and parent must take specific documents and must apply for the ID in person. Read the instructions and review the lists on the ADOT Identification Requirements (next page). 14