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Upward Bound Math/Science Application - Parent Section

  1. COMPLETE STUDENT APPLICATION: Please read each question carefully and complete all sections. If you fail to answer all of the necessary questions, your application will be returned to you for completion. The information you provide on this form will be kept confidential.

    Deadline: 5 p.m., Friday, November 20, 2020

  2. COMPLETE PARENT AGREEMENT: Please make sure your parent completes the Parent Agreement and provides necessary documentation.
  3. THREE LETTERS OF RECOMMENDATIONS: You will need three letters of recommendation from a Math Teacher, Science Teacher, and your Counselor.
  4. INCOME ELIGIBILITY: Please submit a copy of last year’s signed tax return to ubms@nwmissouri.edu
  5. DISABILITY: Please send any documentation of a disability that has been verified by your doctor, or other professional to ubms@nwmissouri.edu. This would include a previous IEP (Individual Educational Plan) or 504 Plan, if applicable.
  6. TRANSCRIPTS: Your academic transcripts and records will be requested from your high school counselor, you do not need to provide them.
  7. INTERVIEW: You will be contacted after turning in your application to interview with an UBMS staff members.  The interview will last 15-20 minutes.
  8. QUESTIONS:  If you have questions about the application process, please call our office at 660.562.1538.

Do NOT refresh the page or risk losing your progress.

* indicates required fields. If any information is unknown at this time, please enter N/A in the form field.

Step 1: Demographic Data

Applicant Information

*Applicant Name:

*Applicant Gender:








*Text messages okay?


Step 2: Parent/Guardian Data and Income Eligibility

Note, this information is necessary for determining program eligibility and is required of all families whose children are served by the Upward Bound Math/Science Program. Your cooperation is needed in filling out the information completely. All information provided is kept confidential.

Natural/Adoptive Father Information

*Father's Education: (mark highest level completed)
*Does the student live with the natural/adoptive father?
*Is the natural/adoptive father deceased?





Natural/Adoptive Mother Information

*Mother's Education: (mark highest level completed)
*Does the student live with the natural/adoptive father?
*Is the natural/adoptive father deceased?





Income Eligibility

The following numbers correspond to 2019 taxable income on the federal forms. If the student is married or has legal dependents other than a spouse (i.e. a child), use the student’s tax information. (This information is required by U.S. Department of Education to help determine eligibility for acceptance into Upward Bound Math/Science.)

*Did you complete an Income Tax Return last year?

Please submit a copy of last year’s signed tax return to ubms@nwmissouri.edu, which includes your 1040.

Enter your information below and a brief statement which summarizes your financial situation.

(count everyone currently residing in the household)

Household Member #1


(before deductions)

(before deductions)




Household Member #2


(before deductions)

(before deductions)




Household Member #3


(before deductions)

(before deductions)




Household Member #4


(before deductions)

(before deductions)




Household Member #5


(before deductions)

(before deductions)




Household Member #6


(before deductions)

(before deductions)




Household Member #7


(before deductions)

(before deductions)





Step 3: Consent & Agreements

Consent for Medical Treatment

In case of emergency, please contact the following:

























Allergies & Dietary



Please list ALL medicines/prescriptions your child will take/is currently taking:















I understand that my child will administer his/her own medication at the prescribed dosage and time listed above. I understand that it is my child’s responsibility to take over the counter medications according to package directions.

I hereby give my permission for my child to receive any medical attention, including preventative, routine and emergency care, as deemed necessary by qualified medical personnel, in the event such treatment is necessary during the entire time the student is enrolled in Upward Bound Math/Science. I also understand that neither Northwest Missouri State University nor the Upward Bound Math/Science Program staff can be held responsible for accidents or injuries.

*Do you give medical consent?

Assumption of Risk, Covenant Not To Sue, Release, and Wavier of Liability Agreement

In consideration of the services provided by Northwest Missouri State University, its board, employees, volunteers, participants, and all other persons or entities acting in any capacity on its behalf (collectively, “UNIVERSITY”) in conjunction with the UPWARD BOUND MATH/SCIENCE program (“Event”), I hereby agree to release, hold harmless, covenant not to sue, and discharge UNIVERSITY, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows:

  • (“Minor”) will participate in the Event. I understand that each Academic Year, the Upward Bound program will have eight Saturday Academies involving participating in sessions on campus and traveling to other colleges for campus visits
  • I acknowledge that Minor’s participation in Upward Bound entails known and unanticipated risks, which could result in physical or emotional injury, paralysis, death, or damage to Minor, to property, or to third parties. I understand that such risks include activities at and away from UNIVERSITY. I understand that such risks simply cannot be eliminated.
  • I acknowledge that the unlawful possession/consumption/use/distribution of alcohol or any controlled substance, including the unauthorized possession/consumption/use/distribution of prescription medications, is strictly prohibited. I agree that any violation of this policy may result in Minor’s immediate removal from Upward Bound. I understand that UNIVERSITY will not store or administer prescription medication(s) for Minor. If Minor will be in possession/utilize medication(s) during Upward Bound, I hereby represent that I have explained to Minor the Event’s policy on alcohol and controlled substances. I further represent that I have discussed with Minor the proper use/administration of the medication(s), including frequency and dosages. I understand and agree that Minor is solely responsible for storing/administering any medication(s) as directed by Minor’s physician or healthcare professional.
  • I expressly agree and promise to accept and assume all of the risks associated with Minor participating in Upward Bound. Minor’s participation in Upward Bound is purely voluntary, and I elect to allow Minor to participate despite the risks. If Minor is injured during Upward Bound, I hereby give my consent for UNIVERSITY to contact appropriate medical professional(s) and further consent to any medical treatment that may be required, as determined by a medical professional. I understand that the cost of any such treatment will be Minor’s or my sole responsibility; UNIVERSITY will not be responsible for any cost related to such treatment in any way. I also understand that UNIVERSITY will not be responsible for any medical treatment that Minor receives.
  • I hereby voluntarily release, waive, covenant not to sue, and forever discharge any and all claims of negligence against UNIVERSITY that relate in any way to any activity Minor undertakes in conjunction with Upward Bound, including transportation to, during, and from the Event.
  • Should UNIVERSITY, or anyone acting on its behalf, be required to incur attorney’s fees and costs to enforce this Agreement, I agree to indemnify and hold them harmless for all such fees and costs.
  • I understand that UNIVERSITY does not maintain an insurance policy that would provide coverage if Minor is injured during the Event or causes any injury during Upward Bound. I certify that I have adequate insurance to cover any injury or damage Minor may suffer or cause while participating in Upward Bound, or else I agree to bear the costs of such injury or damage myself.
  • I understand that UNIVERSITY may photograph, film, and/or record (“Medium”) Minor’s participation in Upward Bound. I authorize UNIVERSITY to use Medium and Minor’s likeness in conjunction with any UNIVERSITY marketing and/or promotional materials, including, but not limited to, social media accounts. I understand that neither Minor nor I will be compensated in any way for such use.

In the event that I file a lawsuit against UNIVERSITY, I agree to do so solely in the State of Missouri, and I further agree that the substantive law of Missouri shall apply without regard to conflict of law rules. I agree that if any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By checking "Yes" below, I expressly state that I have had sufficient opportunity to read this entire Agreement and agree to be bound by its terms.

I further acknowledge that this document contains a negligence waiver and indemnification provisions.

*Do you agree to the above "Assumption of Risk, Covenant Not To Sue, Release, and Wavier of Liability Agreement"?

Parent/Guardian Agreement

I attest to the fact that the above information is true and accurate to the best of my knowledge.

I understand the purpose of the Northwest Missouri State University TRIO Upward Bound Math/Science Program, which is to prepare participants to successfully complete a program of postsecondary education. As part of my personal effort in this preparation, I commit to Upward Bound Math/Science and intend to participate in all academic year and summer components of the program. I understand that attendance is an integral part of participating. Therefore, I agree to attend and actively participate in all classes, meetings and activities sponsored by Upward Bound Math/Science. I will comply with all rules and regulations of the TRIO Upward Bound Math/Science Program, and I am aware that failure to comply could result in dismissal from the program.

*I understand and willingly commit to meeting these expectations.

By submitting this form, I certify that all the information I have typed into this form is correct and I understand that any false information (or omissions) in the contract agreement or its supporting documents will be sufficient grounds for my dismissal in the TRIO Upward Bound Math/Science program. I agree to all the above statements and will fully participate in the TRIO Upward Bound Math/Science program.

To retain a copy of this application for your records,
PLEASE PRINT THIS PAGE NOW!

 

    

 

Northwest Missouri State University
Upward Bound Math & Science
Administration Building 362 - West Wing
800 University Dr.
Maryville, MO 64468

Phone: 660.562.1538
Fax: 660.562.1631
Email: ubms@nwmissouri.edu