Upward Bound Math Science In School Application
Upward Bound Math Science
Shawnee State University
940 Second St.
Portsmouth, OH 45662
740-351-3439 or 1-877-SSU-UBMS (1-877-778-8267)

First Name:	Middle Initial:	Last Name:
School: Grade:	Social Security Number	Date:
Address:	City:  State:	Zip:
Phone:	Grade Point Average ( please provide a copy of your transcript)	Expected Graduation Date
Race (check one) White African American  Asian Hispanic Native American Other
U.S. Citizen Choose one Yes No	Email Address
With Whom Do you live? Both ParentsOne-parent Parent and Stepparent Guardian Grandparent(s) Foster Parent(s) Spouse Other
Personal Information on Male Parent/Guardian
First Name:	Middle Initial:	Last Name:
Address:	City:  State:	Zip:
Occupation:	Employer:	Phone:
Personal Information on Female Parent/Guardian
First Name:	Middle Initial:	Last Name:
Address:	City:  State:	Zip:
Occupation:	Employer:	Phone:
For Parent or Guardian to Complete
In order for your child to participate in this program, you are required by the U.S. Department of Education to provided the following information:
Please select the number in your household: 1 2 3 4 5 6 7 8 9 10
Please select your taxable income which can be found on Line 42 on 1040; Line 24 on 1040 A; Line 6 on 1040EZ on your Federal income tax return:
Less than $14,355	$24,136 - $29,025	$38,806 - $43,695
$14,356 - $19,245	$29,026 - $33,915	$43,696 - $48,585
$19,246 - $24,135	$33,916 - $38, 805	More than $48,586
Did you file income tax forms last year? Choose one Yes No
Do either of the applicants parents/guardians, with whom the applicant lives, have a four-year college degree?
Choose one Yes No
Please provide us with your current class schedule (please indicate if your school has block scheduling):
Period	Subject	Teacher
1
2
3
4
5
6
7
Two favorite courses:
Two least favorite courses:
Name of school counselor: and Phone:
Autobiography (minimum of 1 page in length)
In order to better assist us in determining your needs as a potential UBMS student we ask that you write/type a 1 page autobiography.  when composing your autobiography each of the following areas must be addressed: Personal History Educational Goals (High School and College) Career Goals Why are you interested in Math or Science? Why are you intereswted in the Ubward Bound Math Science program?