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Upward Bound Math and Science_ The Regional Center


									      Upward Bound Math and Science, The Regional Center
                             California Lutheran University

                       GENERAL STUDENT INFORMATION

Name: _______________________________________ SSN: ______-____-________
       Last             First               Middle

Home Address: ___________________________________________ Apt No. ______

City: _____________________________ State: ______ Zip Code: _______________

Email: ____________________________          Telephone: __(     )_________________

Gender: _____M _____F Date of Birth: ____________ Birthplace: ______________

Ethnicity:      a)___Asian           b)___African American        c)___Caucasian

                d)___Latino/Hispanic e)___American Indian         f)___Native Hawaiian

                g)___Other ___________________________

Are you a U.S Citizen or Permanent Resident of the United States? ____Yes ____ No

High School: _____________________________ District: _____________________

School Address: ________________________________________________________

City: ______________________         State: _____     Zip Code: _____________

Telephone: _(     )_________________                 Fax: _(   )__________________

Counselor Name: _________________________ Telephone: _(            )______________

Traditional School Year (Sept-June, with summer vacation) ____Yes ____No

Grade: ____ Cumulative HS GPA: ____ Expected Date of Graduation: ____________

Are you interested in a career in the field of Math and/or Science? ____ Yes ____ No

What area of study do you want to pursue in college? __________________________

Do you participate in a TRIO program (Upward Bound, Talent Search) ____Yes ___No

                                PROGRAM INFORMATION

                                STUDENT APPLICATION
        Upward Bound Math and Science, The Regional Center
                             California Lutheran University
Are you willing to participate in mandatory tutoring sessions if needed?
                      ____ Yes       ____ No

Are you willing to participate in a six-week summer residential program at CLU?
                      ____ Yes         ____ No

                                STUDENT QUESTIONAIRE
             Answer all questions honestly and clearly. Use additional paper if necessary

   1.    List all math and science classes that you are currently registered for this school

   2. Are you currently a participant of another TRIO Program? (i.e. Upward Bound,
      Talent Search) If answer is yes, please name program, institution and name of
      Program Director.

   3. How did you hear about the Upward Bound Math and Science Regional Center at
      California Lutheran University?

   4. What activities are you involved with outside of school?

   5. Do you feel that your grades reflect your potential as a college bound student? If
      so, what do you think the Program can do to help you improve?

   6. Do you currently have a part-time job? If yes, how many hours a week do you

   7. In what subject area(s) do you feel you need the most assistance?

                                 STUDENT APPLICATION
      Upward Bound Math and Science, The Regional Center
                                California Lutheran University
    8. On a separate sheet of paper, submit a typed autobiographical essay of at least
       five paragraphs in length describing the following:
       - Introduce and talk a bit about yourself. (family, challenges, interests, etc)
        - Include why we should consider you for acceptance into the UBMS program at CLU.
        - Discuss why it is so important for you to go to college
        - Tell us why you are interested in pursuing an area of study in the fields of Math and Science

                                  PARENT QUESTIONAIRE

Applicant’s parent(s) or guardian(s): Please provide the following information in order
for us to evaluate your child’s eligibility for the Upward Bound Math and Science
Program. The information you provide will highly confidential.

Applicant’s parent(s) or guardian(s): This information will be highly confidential.

______________________________                                ______________________________
Father’s Name (Male Guardian)                                 Mother’s Name (Female Guardian)

Cell/Work: ____________________                               Cell/Work: ____________________

Please indicate the highest level of educational attainment by each parent or guardian:

Father: Elementary____             High School____            College____ Post Grad____
Mother: Elementary____             High School____            College____ Post Grad____

If highest level of educational attainment is college or higher, please state the Degree or
Certificate completed by each parent:

Father: _______________________                      Mother: ___________________________

        _______________________                                  ___________________________
        (Occupation)                                             (Occupation)

        ____________________________                            ________________________________
        (Employer)                                               (Employer)

Indicate the total amount of taxable family income as is reported on the most recent
Federal Income Tax Return Forms:
    a) $_____________________                 b) Size of Household: ___________
                   (Please include a copy of your most recent tax forms)

                                   STUDENT APPLICATION
       Upward Bound Math and Science, The Regional Center
                                California Lutheran University
If you did not file an income tax return, for the most recent tax year, please indicate your
source of income from the options below:

Disability___ Social Security___ Unemployment___ Veteran’s Benefits___
Other___      Specify:_______________________________________________

       There is separate component to the application which must be submitted along
with the rest of this application to ensure that the application is deemed complete and
ready for consideration. The Letter of Recommendation is to be filled and signed by
both the student and a Counselor or Teacher. This document is the last page of the
application which is to be removed and handed to the appropriate recommender. The
recommender can then either return the document to the applicant, or directly mail it to
the UBMS office, to the address provided on the letter of recommendation

I certify that the information stated above is true and complete to the best of my

I hereby grant permission to the personnel of child’s school to provide copies of
transcripts, test scores, and academic progress reports to the Upward Bound Math and
Science staff.

Upon admission of my child into the program*, I agree to participate in all meetings,
orientation sessions, or workshops organized by the program for the purpose of
improving my child’s chances of personal and educational success.

______________________________________                         _________________________
Student Signature                                              Date
______________________________________                         _________________________
Father’s Signature                                             Date
______________________________________                         _________________________
Mother’s Signature                                             Date

 The Upward Bound Math and Science Program at California Lutheran University is funded by the U.S.
                          Department of Education; grant year 2009-2010, $297,034.
 *This program is available to all children without regard to race, color, national origin, gender, religion,
age, disability, or political affiliations. Any person who believes that she or she has been discriminated in
   any USDE or USDA related activity, should write to the Secretary of Education or the Secretary of
                                       Agriculture, Washington D.C., 20250.
**Final Placement into and continuation with the program will be under the sole
discretion of the Director**

                                    STUDENT APPLICATION
       Upward Bound Math and Science, The Regional Center
                               California Lutheran University
                                          LETTER OF RECOMMENDATION
Applicant: Print in ink or type your name, grade level, and current date on the top portion of this form,
then give it to a counselor, teacher, or adult in your community who will recommend you to our program.
Do not give this form to a relative or friend.

Student's Name                                                   Grade:               Date:

Counselor, Teacher, or Adult: The above named student is interested in participating in the Upward Bound
Math and Science (UBMS) Program at California Lutheran University (CLU). UBMS is an educational
program designed to prepare and help motivate students who have the potential for success in post-
secondary education.

We would appreciate your honest appraisal of this student and his/her potential for benefiting from
participation in the UBMS Program. Please use the space provided to comment on the relative strengths
and weaknesses of the student, how long you have know him/her, and in what capacity. Please return this
form to: Upward Bound Math and Science, California Lutheran University, 60 West Olsen Road #3700,
Thousand Oaks, CA 91360

      Place the most correct number (see scale below) in the space preceding each statement.
                  4 = Strongly Agree     3 = Agree     2 = Disagree       1 = Neutral

                              Expresses interest in his/her academic endeavors
                              Is motivated to achieve in his/her classes
                              Has good attendance record
                              Shows responsibility in his/her endeavors
                              Demonstrates punctuality
                              Cooperates with school officials
                              Relates well to peers
                              Has expressed interest in post-secondary education
                              Demonstrates cultural awareness
                              Would benefit from supplemental educational enrichment
                              Exemplifies dependable and reliable behavior
                              General appearance reflects a positive self-image
Comments: _________________________________________________________________________

I hereby:          highly recommend                   recommend               recommend with reservation
                                                  for admission into the MSUB Program at CLU.
             Student's Name

 Signature                                                       Print Name

 Position and School/Agency                                            Telephone Number

I have known the student for…                                        In my capacity as…

                                   STUDENT APPLICATION

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