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Application for Enrollment 

 Urban Scholars Program 

 Telephone: 617.287.5830

 Email: urbanscholars@umb.edu

Office Location: McCormack 3rd Floor, Room 008

Urban Scholars Website

What is the Urban Scholars Program at UMass Boston?

Urban Scholars is a year-round college-access program that offers tutoring, after-school classes, college-focused programming, field trips and advising as well as an intensive six-week summer institute at the University of Massachusetts Boston. View our latest summer recap.

The mission of the Urban Scholars Program is to identify and to prepare academically motivated high school students from select Boston Public Schools (ages 14-19). In particular, Urban Scholars looks to serve those who are low-income and/or first-generation college bound students, giving them the tools necessary to successfully enroll in and complete college.

We provide our students with the skills and attitudes necessary to achieve their full potential through a structured sequence of after-school classes, tutoring, and summer academic courses and activities designed to build a strong repertoire of basic and higher-level skills, task commitment, and self-motivation.

Who may apply?

A student may apply if they:

  1. Are a U.S. citizen or permanent resident of the United States, and
  2. Is currently in the ninth, tenth, or eleventh grade at Dr. Albert D. Holland High School of Technology, TechBoston Academy, Excel High School, or Dearborn STEM Academy or is a rising ninth grader planning to attend one of these high schools. 

How much does it cost?

All services and activities are provided FREE of cost to participants and their families. The program operates with funds from foundation and corporation grants, institutional contribution, and private donations.  

What benefits does a student receive from participating in Urban Scholars?

  • A 6-week summer institute at UMass Boston. Students take courses in college preparatory subjects and participate in college-ready workshops and activities.
  • Courses and after-school tutoring services during the school year
  • College and career exploration through college tours, fairs, and field trips
  • College and financial aid application assistance for seniors 
  • Internship, university courses, and leadership opportunities 
  • Cultural activities

 

Thank you for your interest in our Urban Scholars program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application.  You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.  If you have any questions, please contact our office.
Date *

PART 1: STUDENT INFORMATION

DEMOGRAPHIC INFORMATION 
First Name *
Middle Name
Last Name *
Age *
Date of Birth *
Place of Birth *
Gender *
Home Address *
Apt.
City *
State *
Zip Code *
Cell Phone Number *
Email *
Mailing Address (if different)
City
State
Zip Code

ETHNIC AND RACIAL BACKGROUND

Please respond to each of the following two questions. This information is used for the purpose of reporting to prospective funders. It is reported in the aggregate (about Urban Scholars students as a whole, not individually).
1. Ethnicity: Are you Hispanic/Latino? *
2. Race (please select all that apply):
American Indian/Alaskan Native *
Asian *
Black or African American *
Native Hawaiian or other Pacific Islander *
White *

LANGUAGE INFORMATION

Please respond to each of the following three questions. This information is used to assess students' academic needs and to plan appropriate services and support. 
Is English your first language? *
Is English the primary language spoken at home? *
If no, what language is mainly spoken at home?

PART 2: CONTACT INFORMATION
Parent/Guardian 1 Name *
Parent/Guardian 1 Phone *
Parent/Guardian 2 Name
Parent/Guardian 2 Phone
EMERGENCY CONTACT INFORMATION
Emergency Contact Name *
Emergency Contact Phone *

PART 3: EDUCATIONAL AND EMPLOYMENT INFORMATION
Name of high school *
Grade *
Name of high school guidance counselor
School ID Number
Please choose the highest level of education that you (the student) aspire to complete.
GED
High School
Career or Vocational Degree Program
Two-year College
Four-year College
Master's Degree
Doctoral Degree
Are you currently on an Individualized Education Plan (IEP) for a learning disability? *
If yes, please upload a copy of your IEP

HONORS AND AWARDS

Please list any awards or honors (scholastic and other) that you have achieved during your middle and high school years. 
Award and date received (month/year)

EXTRACURRICULAR ACTIVITIES

Please list any extracurricular activities (athletics, clubs, etc.) that you currently participate in, in their order of importance to you.   
Activity, hours per week, and position held (if applicable)
Do you currently participate in any other educational opportunity or enrichment programs? (Please check all that apply)
Bottom Line
College Bound
Educational Opportunity Center (EOC)
GEAR UP
TRIO Talent Search/Project REACH
Other:
What will interfere with your being able to complete the program? (Check all that apply)
Chores and responsibilities at home
Church activities
Extracurricular activities such as sports, dance team, school clubs, etc.
Family vacations
Getting bored easily
I don't foresee anything that would keep me from completing the program
Missing my friends
Other:
EMPLOYMENT ACTIVITIES
Do you have a job or internship? *
If yes, how many hours per week do you usually work?
Under 10 hours per week
Between 10-15 hours per week
Between 16-25 hours per week
Over 25 hours per week

PART 4: STUDENT CONTRACT OF PARTICIPATION

I will meet the following requirements as an Urban Scholars participants:

  1. I will work toward maintaining at least a 3.0 or B average in all of my high school classes.
  2. I will participate in developing my social and academic skills for graduation from both high school and college.
  3. I will attend the 6-week summer institute or complete a pre-approved alternative summer project.
  4. I will participate in tutoring and special activities during the academic year. I understand that excessive absences will be reason for disciplinary action or termination.
  5. I will ensure that I notify the program in the event of a cancellation for any trips/activities that I have signed up to be part of. In the event of a cancellation without prior notice, I understand that I will be responsible for the cost of my scheduled participation.
  6. I will follow all rules of the Urban Scholars Program and UMass Boston.
  7. I will follow the directives of Urban Scholars administrators, instructors, and tutors.
  8. I will show respect for myself, the teachers, tutors, and my fellow Urban Scholars students.

By signing below, I indicate my intention to follow the requirements listed above. I understand that if my commitment is found to be lacking in any of these areas, it will result in disciplinary action, up to and including dismissal from the program.

 
Student signature *
Please select a signature verification type.

PART 5: ESSAY QUESTIONS

Please write an essay that answers the following questions.
1. What are your college and professional goals?
2. Why are you interested in the Urban Scholars Program, and how will enrolling in the program contribute to your academic and professional goals?
If you typed your essay, please upload it here.

PART 6: DEMOGRAPHIC AND ELIGIBILITY INFORMATION
How many people in your household?
Taxable income
Please upload a copy of income tax form (1040 or 1040EZ) or a copy of a letter from the Department of Transitional Assistance and/or Social Security Office
VERIFICATION OF U.S. CITIZENSHIP/RESIDENCY
Student's Social Security Number
Is the student a United States citizen? *
If no, what is the student's country of citizenship?
If no, what is the student's Permanent Resident Card (Green Card) number?
Please upload a copy of the student's Social Security Card and, if applicable, a copy of their Permanent Resident Card.
FIRST GENERATION VERIFICATION
With whom does the student live? *
Mother/adoptive mother
Father/adoptive father
If either parent graduated from a four-year college, what country was the degree completed in and what degree was received?
Mother/adoptive mother (country and degree)
Father/adoptive father (country and degree)

PART 7: PARENT CONTRACT OF PARTICIPATION

I will meet the following requirements as an Urban Scholars participant’s parent/guardian:

  1. I will work with m child toward maintaining at least a 3.0 grade point average, or B average, in all of his/her high school classes.
  2. I will ensure that my child follows the rules of the program.
  3. I will ensure that my child attends and completes the Summer Institute or completes a pre-approved alternative summer project.
  4. I will encourage my child to participate in tutoring and special activities during the academic year.
  5. I will not allow my child to be involved with drugs or alcohol. I understand that the use or possession of drugs or alcohol is not tolerated and will result in my child’s immediate dismissal from the program.
  6. I will participate in program activities when a parent/guardian’s presence is required.
  7. I will respond to inquiries from the program staff regarding my child.
  8. I understand that if my child does not fulfill his/her commitment to the program. He/she may be dismissed.

By signing below, I agree to support the program’s mission and my child’s commitment to the program.

Parent/guardian signature *
Please select a signature verification type.

PART 8: RELEASES OF INFORMATION
Student Name *
Parent/Guardian Name (completing this form) *

PARENT PERMISSION TO RELEASE INFORMATION TO URBAN SCHOLARS

I, the parent/guardian of the student named above, do hereby permit the release of my child's academic records including but not limited to grades, individual education plans, standardized test scores, and proof of graduation to Urban Scholars at UMass Boston. In addition, I hereby authorize post-secondary institutions to release to Urban Scholars copies of academic, enrollment, and student aid award information from the college/university my child will attend after high school.

I understand that all information will be kept confidential and that records will be used assessing student needs, monitoring student progress, documenting eligibility for the program and for reporting purposes. The information shall only be transferred to a third party outside of UMass Boston and the Urban Scholars program on the condition that written consent of a parent(s)/guardian(s) (or applicant, if over 18) is first obtained.
Parent/guardian signature *
Please select a signature verification type.
Date *

PARENT PERMISSION TO RELEASE INFORMATION TO EXTERNAL PARTNERS

I, the parent/legal guardian of the student named above, do hereby permit Urban Scholars at UMass Boston to release the academic records of my child and his/her participation in Urban Scholars to the Boston Public Schools, the Massachusetts Department of Elementary and Secondary Education for legitimate educational interests and to release the following information about my child to Boston After School and Beyond (http://www.bostonbeyond.org) for a data integration project: name, date of birth, race/ethnicity, high school, student ID number, and home zip code.
*
Please select a signature verification type.
Date *

STUDENT PERMISSION TO RELEASE INFORMATION TO URBAN SCHOLARS

I, the student named above, do hereby permit the release of my academic records including but not limited to grades, individual education plans, standardized test scores, and proof of graduation to Urban Scholars at UMass Boston. In addition, I hereby authorize post-secondary institutions to release to Urban Scholars copies of academic, enrollment, and student aid award information from the college/university I will attend after high school graduation. Specifically, I authorize the release of my college transcript and/or degree audit showing grades earned, any remedial courses taken, degree(s) earned, and financial aid awarded.
*
Please select a signature verification type.
Date *

MEDIA RELEASE

Beginning as of the date of execution of this release, that photographs, whether still or action, videos, film and/or motion pictures (hereinafter "Pictures") and/or audio recordings ("Recordings") may be taken of my child, individually or with others, by or on behalf of UMass Boston in connection with this youth program, and agree that all rights therein shall irrevocably, exclusively, unconditionally and perpetually belong to UMass Boston and that such rights are freely assignable by UMass Boston. I further agree that, without any compensation or notification to or approval by me, the Pictures or Recordings, and website postings may be used, reproduced or otherwise disseminated or published by or on behalf of UMass Boston directly or indirectly for any purpose, including but not limited to advertising and/or promotional purposes, in any manner, and at any time that UMass Boston desires. For good and valuable consideration, receipt of which is hereby acknowledged, I hereby agree to release and discharge UMass Boston, its trustees, directors, officers, employees, servants, representatives, agents, licensees, successors and assigns from any and all claims, demands or causes of action that I may now have or may hereafter have for libel, defamation, invasion of privacy or right of publicity, infringement of copyright or violation of any other right arising out of or relating to any utilization of the Pictures or Recordings.
Parent/Guardian Signature *
Please select a signature verification type.
Date *

PART 9: STATEMENT OF CERTIFICATION

By signing below, I certify that all of the information by me or any other person on this application is true and complete to the best of my knowledge. 
Parent/Guardian Signature *
Please select a signature verification type.
Student Signature *
Please select a signature verification type.
Date *