Fillable FillableUBMSStudentApplication12-17-18 Educational Talent Search

Fill Online, Printable, Fillable, Blank FillableUBMSStudentApplication12-17-18 Educational Talent Search Form

Use Fill to complete blank online CENTRAL CONNECTICUT STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FillableUBMSStudentApplication12-17-18 Educational Talent Search

On average this form takes 27 minutes to complete

The FillableUBMSStudentApplication12-17-18 Educational Talent Search form is 3 pages long and contains:

  • 0 signatures
  • 61 check-boxes
  • 78 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Central Connecticut State University

BROWSE CENTRAL CONNECTICUT STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Pg. 1
TRiO Programs are funded by the United States Department of Education Revised, 12/17/2018
Central Connecticut State University
2018-2019 TRiO Upward Bound Math Science Enrollment Application
Mission Statement:
The Upward Bound Math Science (UBMS) program provides program participants with exposure to careers in science,
technology, engineering and math (STEM), preparation for the rigors of pre-college courses, programs offered throughout
the year, and entrance into higher education. Once a student has been accepted into TRiO UBMS, there is no need to apply
again for the program. Students stay enrolled in TRiO UBMS until they graduate from high school or the student moves out
of the Consolidated School District of New Britain.
The information you provide is private and used solely to determine eligibility, report data, and track student success.
Please visit our website at http://www.ccsu.edu/trio for more information regarding programming.
BRING OR MAIL APPLICATION TO:
The main office in your student’s school or to TRiO Director, Office of TRiO Programs at Central Connecticut State
University, Institute of Technology and Business Development, 185 Main Street, Suite 218, New Britain, CT. 06051 or
Fax to: 860-832-2235. You can also scan and email this application to TRiO Director, Andres Sovero, at
soveroa@ccsu.edu
. Actual Signatures are required for this application to be processed.
STUDENT INFORMATION – CONFIDENTIAL, Please print using a black or blue pen.
Name of Student: ________________________________________________________________________________________
(First) (Middle Initial) (Last)
Mailing Address (include Floor or Apt #):
New Britain, CT. Zip Code: Email:
(1) Home Phone: __________________________________ (2) Cell Phone: ___________________________________
Gender: □ Male □ Female Marital Status: □ Single □ Married □ Divorced Date of Birth: _____ / ___ / ____
Ethnic Background:
MM DD YYYY
□ Hispanic/Latino □ American Indian or Alaska Native, non-Hispanic/Latino □ Asian, non-Hispanic/Latino □ Black or African
American, non-Hispanic/Latino □ White, non-Hispanic/Latino □ Native Hawaiian or Other Pacific Islander, non-
Hispanic/Latino □ Two or more races, non-Hispanic/Latino □ Race or Ethnicity Unknown
U.S. Citizen? □ Yes □ No or Permanent Resident? Green Card #:
U.S. Veteran? □ Yes □ No
Are you currently enrolled in another TRiO Program (Educational Talent Search)? □ Yes □ No
EDUCATION INFORMATION – CONFIDENTIAL
Name of School: Current Grade Level: GPA:
(18-19 school year) (6
th
- 12
th
) (18-19 school year)
Name of Counselor: Student ID:
Do you want to go to college? □ Yes □ No □ Not Sure If Yes, Name of College: __________________________________
Alternate Education: □ Out of school □ CDP □ GED □ Adult Ed □ Other: ________________________________
Pg. 2
TRiO Programs are funded by the United States Department of Education Revised, 12/17/2018
ELIGIBILITY INFORMATION– CONFIDENTIAL
Parent/Guardian #1 Name and Phone Number:
Parent/Guardian #2 Name and Phone Number:
Parent/Guardian #1 & 2 Emails:
Language spoken in the home: □ English only □ English and
□ Only a language other than English (specify)
Required - Does Parent/Guardian #1 have a four-year U.S. college degree (B.A. or B.S.): □ Yes □ No □ Not Sure
Required - Does Parent/Guardian #2 have a four-year U.S. college degree (B.A. or B.S.): □ Yes □ No □ Not Sure
FINANCIAL INFORMATION – CONFIDENTIAL
Answer Section A or B below, but not both
A Total number of exemptions claimed on Federal 1040/1040A/1040EZ tax form (including applicant):
Taxable Income from the most recent Federal 1040/1040A/1040EZ tax form: (Do not use Adjusted Gross Income
for the table below; use “Taxable” Income - found on page 2 of the 1040 tax return)
OR
B I did not file Federal 1040/1040A/1040EZ taxes but my income is: $ per: □ week □ month □ year
My income is from (check all that apply) □ Job □ Unemployment □ TANF □ Disability □ Other
**Required**: Total number of family members living at home (including applicant): ___________
ADDITIONAL INFORMATION – CONFIDENTIAL
UBMS SERVICES
PHOTOGRAPHY AGREEMENT AND RELEASE
□ $0 – $18,210
□ $31,171 – $37,650
□ $50,611 – $57,090
□ $18,211 – $24,690
□ $37,651 – $44,130
□ $57,091 – $63,570
□ $24,691 – $31,170
□ $44,131 – $50,610
□ $63, 571 – Over
My student requires special accommodations to participate in activities outside of the school:
□
Yes
□
No
If yes, describe:
My student has the following medical conditions: (Please describe):
My student is allergic to the following medications, foods and/or substances (Please list):
Please check TRiO UBMS services needed or wanted: (Select Multiple)
□
Intensive Summer Programs
Exposure to Cultural Events
□
Financial Aid Application Assistance
□
Academic Counseling
Tutoring Services
□
Application Fee Assistance/Waiver
□ Exposure to University Faculty
□ College Entrance Exams Preparation
□ Computer Training
□ Financial Aid/ Scholarship Information
□ Scientific Research
□ Parental Involvement and Support
Pg. 3
TRiO Programs are funded by the United States Department of Education Revised, 12/17/2018
I authorize the use of my student’s/my photo by UBMS for publicity and recruitment purposes for the duration of their/my
involvement in the UBMS program. □ Yes □ No
STUDENT SIGNATURE: Date
PARENT/GUARDIAN SIGNATURE: Date
******************************************************************************************************
RELEASE OF RECORDS
Students Name (print): School:
The Release of Records is essential and required for TRiO Upward Bound Math Science (UBMS) staff to provide appropriate services. The
information requested will be relative to and consistent with my student’s/my education. Such information may include, but is not limited to
copies of school transcripts, test scores, free and reduced lunch eligibility, class schedules, attendance and financial aid information for as
long as my student is/I am enrolled in the UBMS program. I authorize the representatives of my student’s/my secondary school to release
said records to the UBMS staff for purposes stated above.
Further, we/I authorize UBMS representatives to communicate with representatives from postsecondary institutions on my student’s/my
behalf for up to six-years after high school graduation. This also authorizes the postsecondary institution in which my student/I am enrolled to
release information on admissions, college academic enrollment and financial aid information including award letters.
This information is used to best determine program services specific to my student’s/my needs for educational progress, program reporting
and verification of postsecondary completion. This information is private and protected under the General Education Provision Act, as well
as the Family Education Rights and Privacy Act. Should you choose not to sign this Release of Records, UBMS may not be able to serve
your student/you, or program services may be limited.
Student Signature Date
Parent/Guardian Signature (if student is under 18) Date
Federal and state laws do authorize the release of private information without your consent to school officials who have legitimate
educational interests in the information; the US Department of Education for the purposes of program compliance; evaluation; in connection
with a subpoena if necessary, to protect your health or safety or the health or safety of others; or if required by a court order.
******************************************************************************************************
STUDENT & PARENT/GUARDIAN AGREEMENT
I, the undersigned, confirm that all the information on this application is true to the best of my knowledge. Further, if my
student is/I am accepted into the TRiO UBMS program, I agree to meet with UBMS Staff regularly, do my best academically
and prepare to enter a Trade School; Technical, 2-Year or 4-Year College after high school.
STUDENT SIGNATURE: Date
PARENT/GUARDIAN SIGNATURE: Date
FOR OFFICE USE ONLY:
U.S. Citizen or Permanent Resident Submitted all signed documents
Completed 5
th
Grade, 11-27 years old, OR meets criteria for adult participation Missing signed documents
*********************************************************************************************************************************************************************
□ LI/FG □ LI □ FG □ OTHER Verified
*********************************************************************************************************************************************************************
□ Add □ Waiting List □ Pending □ Not Eligible (Reason)
*********************************************************************************************************************************************************************
UBMS Staff Initials Date Director’s Initials Date
Academic Transcript Recommendation Letters UBMS Application Personal Statement
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FillableUBMSStudentApplication12-17-18 Educational Talent Search

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 March 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document