The Upward Bound Math and Science program is designed to strengthen the math and science skills of participating students. The goal of the program is to help students recognize and develop their potential to excel in math and science and to encourage them to pursue postsecondary degrees in math and science, and ultimately careers in the math and science profession. Our partnership for the program are two high schools in our community; Orange High School and El Modena High School. 

Please complete the following application below. 

Student Information: To be completed by the student.

If section(s) not applicable to you, write NA

First Name *
Middle Name
Last Name *
Age *
DOB *
Gender *
Student ID Number *
High School *
Current Grade Level *
Year of Expected Graduation *
Current GPA - Check your Aeries *
Local Address *
Local City
Local State *
Local Zip *
Home Phone Number *
Student Cell Phone Number


 

Are you a U.S. Citizen? *
Permanent U.S. Resident *
Permanent Residency Number
Hispanic *
Race - White *
Race- African America *
Race- Asian *
Race - American Indian / Alaskan *
Race- Native *
Race - Hawaiian/ Other Pacific Islander *
Race - Other *
If American Indian, which tribe(s):
Primary Language Spoke at Home: English, Spanish, Vietnamese, Other *
With whom do you reside and receive support from? Please indicate if parents, grandparents, aunt, uncle, other. *


PARENT INFORMATION:

(Must be completed by parent or guardian with whom applicant lives)

ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE

If section(s) not applicable to you, write NA. 

Select one: Mother/Stepmother/Guardian *
Name *
Occupation *
Cell Phone Number *
Work Phone Number
Parent Email *
Highest Level of Education Completed: *
Has Parent/Guardian completed a four-year University/College (Bachelor’s Degree) in the U.S.? *
Language spoken by parent: *
Father/ Stepfather/ Guardian
Name
Occupation
Cell Phone Number
Work Number
Parent 2 Email
Highest Level of Education Completed:
Has Parent/Guardian completed a four-year University/College (Bachelor’s Degree) in the U.S.?
Is there any physical or emotional condition(s) your child has which UBMS staff should be aware of? *


Student Survey:

Please answer the following questions: 

How did you hear about Upward Bound? *
Have you performed any voluntary community service? *
Do you plan to continue your education after high school graduation? *
Please explain if you would like to attend a 2-year (community college) or 4-year (university) after high school? *
Are you interested in Math and/or Science Careers?
List your top 3 career interests: *
What areas of school do you need help with? *
What other programs or sports are you involved in? List all activities. *
Do any of these activities require Saturday participation? *
Do you have a job?
If yes, how many hours do you work?
Are you able and willing to attend 2 Saturday meetings per month in the academic year? *
Are you able and willing to attend the six-week summer program each year? *
Requirements vary during stay at home order: Are you able and willing to participate in 2 hours per week of tutoring during the academic year? *
Are you able and willing to participate in academic workshops twice a month after school?
Are you able and willing to participate in academic reviews with the support specialist once a week? *


Student Essay: 

Please, write a minimum of 300 words. Use the space below to describe why you want to participate in Upward Bound Math and Science and how you think you will benefit from the experience:

Complete Essay: *


FAMILY SIZE AND INCOME INFORMATION 

Family size: (if applicable, line 6d on 1040 Income Tax Return) *
Taxable income : (if applicable, line 37 on 1040 Income Tax Return) *
Certification: We certify that the responses on this form are accurate and complete to the best of our knowledge and that any misrepresentation may be cause for denial or cancellation of admission. We understand that we may be requested to provide income documentation and proof of citizenship if admitted into the Upward Bound Math & Science Program.  
Student Email *
Parent Email