Fill - Free fillable UBMS-application Pasadena City College UBMS New Student Application PDF form

PASADENA CITY COLLEGE TRIO

UPWARD BOUND MATH/SCIENCE

APPLICATION

(TO BE COMPLETED BY PARENT/GUARDIAN)

1570 East Colorado Blvd.,

Pasadena, CA 91106

(626) 585‐3114

msubstaff@pasadena.edu

Ed. Advisor:

______________

Is the student in

any of these  AVID Upward Bound  Upward Bound Math/Science Cal SOAP Talent Search

programs?

Other_________________

Math Science Upward Bound is a NO COS

program designed to provide supplemental college readiness services to students who are

committed to continuing their studies in a STEM major after high school graduation.

       

   

 



    

   

 



      



           



                   

            

 



      



         



          



            



 

    

             



          



        

         



            



 



     

     

     



                 

   

                 



  



                   



         

         



  



                  

              

                  

    



                   

               



  

 



  



  



                 

STUDENT INFORMATION

Name of School: _____________________________________ Counselor’s Name/Phone Number:____________________________

Student’s First Name: ____________________________ Middle Name: ___________________ Last Name: ____________________

Student’s email address: _______________________ Social Security #: ______________ Current Weighted GPA: ______

Street Address/P.O. Box: ____________________ City: _____________ Zip Code: _______ Phone #: (____) ____‐______

Student’s Gender:

 Male  Female

Age: ______ Date of Birth: _______________ Grade Level:







Student’s Citizenship Status:



U.S. Citizen



Permanent Resident #: ____________________

Student’s Race/Ethnicity:



Hispanic/Latino



Asian/Pacific Islander



African American



Native American/Alaska



Hawaiian/Pacific Islander



Other, specify_________________

ALL INFORMATION PROVI DED IS CONFIDENTIAL AND WILL NOT BE SHARED WITHOUT PARENTAL PERMISSION.

PARENT/GUARDIAN INFORMATION

Father’s Name: _______ ____________________________ Mother’s Name: _________________________________

Cell Number: ____________________________________ Cell Number: ____________________________________

Email address: ____________________________ _______ Email address: ___________________________________

Work telephone: ________________________________ Work telephone: _________________________________

Does Father/Guardian Have a Degree?  Yes  No Does Mother/Guardian Have a Degree?  Yes  No

Check Degree: Check Degree:

 Associate Degree  Bachelor’s Degree  Master’s Degree  Associate Degree  Bachelor’s Degree  Master’s Degree

FAMILY INCOME VERIFICATION

How many people are living in your household? _______________ Does student participate in free/reduced lunch at school? Y / N

Family’s Annual Income: $_____________Parent’s Initial:________ Taxable Income: $______________ Parent’s Initial:_______

(Federal Tax Form‐1040/A p.1) (Verification) Federal Tax Form‐1040/A p.2) (Verification)

PARENT/GUARDIAN ACKNOWLEDGEMENT AND CONSENT:

I hereby authorize the Upward Bound Math Science Program at Pasadena City College to obtain transcripts and other academic

cumulative records for the above named student. Information may contain high school graduation requirements: credits

completed and credit deficiencies; grade point average (GPA); college admission test scores such as ACT and SAT; and other

information necessary to provide services.

I certify that all the information provided in this application is accurate. I understand that the Upward Bound Math Science

Program may deny my child’s admission if any information is found to be incomplete or inaccurate.

Student Signature: ________________________________________________

Date: ________________________

Print Parent Name:________________________________________________

Parent Signature: _________________________________________________

Date: ________________________

TRIO Works! TRIO Upward Bound Math & Science is 100% funded by a U.S. Department of Education grant.

Revised 4/27/2017 Name of Staff Member: Date Completed:

click to sign

signature

click to edit

click to sign

signature

click to edit

   

 



    

   

 



   

               

              

               

            

                    

                 

              

     

    



           



              

  



   



                      

           



  

    

     



  

    

     



   

 

                    

                  

                         

                   

   

                        

               

                    

 





  

       



  

      

______________________________________________________________________________________________

PASADENA CITY COLLEGE TRIO

1570 East Colorado Blvd.,

Pasadena, CA 91106

UPWARD BOUND MATH/SCIENCE

(626) 585‐3114

APPLICATION

msubstaff@pasadena.edu

(TO BE COMPLETED BY PARENT/GUARDIAN)

Part II: Essay Questions

What major do you want to take in college? What career are you interested in? ___________________________

INSTRUCTIONS: On a separate piece of paper, please answer the following questions (one paragraph minimum):

1. Please explain why you would like to attend the Upward Bound Math/Science program at Pasadena City

College. In what areas (academic or personal) can our program help you improve?

2. Describe a math or science‐related problem in the world, why is it an issue, and why is it important to you?

3. Why is it important for you to attend college? Is this goal for yourself or for your family?

4. The Upward Bound Math/Science program requires a large commitment on your part. It requires tutoring,

Saturday Academies and summer program. Explain why you think you have the commitment to follow

through on all the required activities.

Part III: Extra Curricular Activities

Please list school, community, sports, and activities you are involved in: ____________________________________

Please list meaningful activities you would like to be a part of in each category:

Career Exploration: _____________________________________________________________________

Academic Preparation: __________________________________________________________________

Personal Development: _________________________________________________________________

Part IV: Emergency Contact

Please give the name, address, and phone number of two adults (relatives or fri ends) who do not live with you, but can be

contacted in the event of an emergency. A TELEPHONE NUMBER IS MANDATORY.

Name: ________________________________ Relationship____________________________

Address: ______________________________ City, Zip _______________________________

Home Phone: __________________________ Cell Phone: _____________________________

Name: ________________________________ Relationship____________________________

Address: ______________________________ City, Zip _______________________________

Home Phone: __________________________ Cell Phone: _____________________________

Part V: Parent/Student Contract

Please initial:

______If selected as a participant of the Upward Bound Math/Science program at Pasadena City College, I agree to participate in the

entire program, including tutorial sessions, the Saturday Academies, and 5 week summer program. Arrangements may be made ahead of

time with the Director or Educational Advisor. If accepted, I will conduct myself in a manner that will bring credit to my family, my school, my

community, and myself. I also agree to abide by the rules and regulations established by the UPWARD BOUND MATH/SCIENCE PROGRAM

during all program activities.

_______I understand that the Director has the right to dismiss any student if the student does not adhere to the rules and regulations of the

program, or is not showing a positive attitude in participating in the activities of the program.

_______ I Understand that priority will be given to students that meet both the federal low‐income guidelines and that neither parent

graduated from colleg

_________________________________ _____________________________ _______________________

Student Name (Print) Student Signature Date

________________________________ ________________________ ___________________

Parent/Guardian Name (Print) Parent/Guardian Signature Date

Revised 4/27/2017 Name of Staff Member: Date Completed:

click to sign

signature

click to edit

click to sign

signature

click to edit

  

       



         



                 

    



      



 

                 

 



                 

                

       









    



    



    



   



Teacher Counselor Recommendation

for Pasadena City College Upward Bound Math/Science Program

1570 E. Colorado Blvd., RM D114, Pasadena, CA 91106▪(626) 585‐3114 ▪msubstaff@pasadena.edu

APPLICANT: Fill out this portion of the recommendation. Give this to a teacher or a counselor who will

recommend you to our program.

Student’s Name: ____________________________ High School: ______________________Grade: ________

Dear Teacher/Counselor:

The student named above is applying to our program which attempts to help low‐income and first generation high

school students improve their achievement in high school for the eventual admission to the college or university of

their choice.

During the academic year we provide students with assistance in their courses and advise them about their college

and career choices. Please provide us your impression of the student. Would he/she benefit from the program and

would he/she contribute to the program’s success? Please comment freely if necessary. If you have any questions,

please call 626‐585‐3114. Thank you for your assistance.

Below

Average

Above

Average

Excellent Top

10%

Outstanding

Top 2%

Ability

Motivation

Self-Discipline

Writing Skills

Oral Skills

Math Skills

Leadership

Self Confidence

Emotional Maturity

Concerns for Others

Personal Initiative

Works well with Peers

Works well with Faculty

Additional Information:

Teacher/Counselor’s Name: ____________________________ School: ___________________________

Position: ____________________________________________ Work Phone: _______________________

Signature:___________________________________________ Date: _____________________________

Revised 4/27/2017 Name of Staff Member: Date Completed:

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

UBMS-application Pasadena City College UBMS New Student Application

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank UBMS-application Pasadena City College UBMS New Student Application Form

Related forms

Fillable UBMS-application Pasadena City College UBMS New Student Application

Fill Online, Printable, Fillable, Blank UBMS-application Pasadena City College UBMS New Student Application Form

Related forms

First 20 documents completely FREE!