Application

The online application must be completed at one time and cannot be saved in progress to be completed at a later time.

The following parts of the application must be provided to the Math and Science Center office in order for your application to be considered. Applications must be completed before a student can be considered for admission to the program. Some of the information requested will help us determine whether the student meets the criteria for entry into the program, and some is to help us know best how to assist your student if he or she becomes a participant. You are responsible for making sure that the completed forms are returned to the Math and Science Center office. Contact our office with any questions you may have.

Please use the following checklist to help you make sure your application is complete:

• Application
• Financial Eligibility Information
  A copy of a tax form or other verification of monthly income must be attached!
• Counselor or Teacher Recommendation
• Transcript

Student Information

First Name

Middle Name

Last Name

Address

City

State

- Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Student Email

Date of Birth

Social Security Number

ex. 999-99-9999

Ethnic Preference

- Select -African American Hispanic Caucasian Native American Asian American/Pacific Biracial/Other

Biracial/Other Please Specify

Citizenship Status

U.S. Citizen

Permanent Resident

Other

Other Citizenship Status

Gender

Male

Female

Decline to Answer

Custom Gender

Let us know how the student prefers to identify. Please include pronouns if applicable.

Current Grade

- Select -8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

Next Grade

- Select -8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

GPA

ex 3.99 (assuming 4 point scale)

High School Attending or Will Attend

School Counselor Name

Teacher or Counselor Recommendation Information

In order to complete your application you must also have a math/science teacher or guidance counselor fill out the required recommendation form. Please give us the name and email of a teacher/counselor who can give us a positive recommendation for you.

Recommender Name

Recommender Email

Current Class Schedule

Hour 1.

Hour 2.

Hour 3.

Hour 4.

Hour 5.

Hour 6.

Hour 7.

Hour 8.

Academic Need

Please check the Math & Science Center services that you are interested in receiving:

Academic Need

ACT/SAT Preparation

College Planning

Study Skills

Test Taking Tips

Academic Advising

Educational/Cultural Trips

Campus Visits

Time Management

College Admissions

Financial Aid Information

Tutoring

Career Guidance Planning

6-week Residential Summer Institute at the University of Kansas

Parent/Guardian Information

Parent/Guardian Name #1

Email

Parent/Guardian #1 Relationship

- Select -Parent Guardian

Parent/Guardian #1 Parent Relationship

- Select -Mother Father

Parent/Guardian #1 Guardian Relationship

Parent/Guardian #1 Bachelor's Degree Completed

- Select -Yes No

Parent/Guardian Name #2

Parent/Guardian #2 Relationship

- Select -Parent Guardian

Parent/Guardian #2 Parent Relationship

- Select -Mother Father

Parent/Guardian #2 Guardian Relationship

Parent/Guardian #2 Bachelor's Degree Completed

- Select -Yes No

Day Time Phone

- -

Evening Phone

- -

Best Time to Call

Morning

Afternoon

Evening

Other Languages Spoken at Home

Family Financial Statement

Did You File an Income Tax Return Last Year?

Yes

No

Found on Line 15 on your 2020 1040 form.
Value cannot contain commas; numbers and decimals only.

Family Size

Total Taxable Income

Found on Line 10 on your 2018 1040 form.
Value cannot contain commas; numbers and decimals only.

Reason Tax Return Not Filed

Information to Determine Financial Eligibility

The Math & Science Center program at the University of Kansas and the U.S. Department of Education require all applicants to submit with their application a signed copy of their parent/guardian’s 1040, 1040A or 1040EX federal income tax form. If you did not file an income tax return this year, please provide a copy of AFDC payment, check stub or other verification of monthly income. If you did file an income tax return, attach a photocopy of your return to this application and sign below.

1040, 1040A, or 1040EX Federal Income Tax Form

Please submit tax form as a PDF

Other Verification of Income

Provide a copy of AFDC payment, check stub or other verification of monthly income.

Certify Did/Will Not File

I certify, under penalty of perjury, that I did not and will not file a U.S. Income Tax Return for the year 2020, and that the financial information provided in this application is true and accurate.

Parental Consent and Release *

I hereby grant permission for my child to participate in the University of Kansas Math and Science Center program, which may include field trips, overnight camping, tutorial sessions, living in residential halls and physical activities. I also understand and acknowledge that transportation for field trips, academic enrichment sessions, conferences, overnight camping and other activities will be by bus, van, train, airplane or private car. Activities may include swimming, canoeing, horseback riding and other activities. In consideration of the activities provided to my child, I hereby release the University of Kansas, Math and Science Center, and their employees from any claims of injury or damages arising out of my child’s participation. I accept responsibility for my child’s conduct while participating in the Math and Science Center, and I hereby release the Math and Science Center from injuries or damages resulting from my child not following and adhering to the rules and policies of the program.

Grant Permission

I grant permission

I agree to the release of my grades, test scores and transcripts by my middle and high school to the University of Kansas Math and Science Center. I understand that the Math and Science Center will also maintain records on my performance in program activities. I agree to the release of this information to staff members and the U.S. Department of Education.

Consent of Release of Educational Information

I agree to the release of grades, test scores and transcripts

Parent/Guardian Signature *

Preferred Signature Method

Sign with mouse or finger on a touch screen device

Typed

Parent Signature - Typed

Please sign in the box below using your mouse or finger if using a mobile or touch screen device.

Parent Signature

Certification

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Submit Form