University Of Dayton-UB

University of Dayton

TRIO Upward Bound Program

Student Application

Medical Information/Emergency Contact
Student’s Doctor and Location
Phone
(999)999-9999
Please list health insurance under which the student is covered: (include medical assistance, if applicable):
Name of Company
Policy and/or Group Number
Has he/she ever been (please check)

Hospitalized Had a serious injury Had surgery or other operations Have/had a serious illness
If you checked any of the above, please explain:
Is he/she currently taking medication?

Yes No
If yes, please specify which one(s) and how often (please feel free to add additional pages if necessary):
Please list ANY medical information that you feel is important for the Upward Bound staff to be aware of regarding your student (this includes allergies, ongoing health issues, medications, and or special dietary needs):
Please list ANY physical restrictions your student should observe:
EMERGENCY CONTACTS (other than persons listed above):
Name

First Name Last Name
Phone
(999)999-9999
Relationship to Student
Name

First Name Last Name
Phone
(999)999-9999
Relationship to Student
Name

First Name Last Name
Phone
(999)999-9999
Relationship to Student
ATTENTION: Upon evaluation, we will seek medical authorities for injuries and/or illness that require medical attention. You will be billed for the costs if your son/daughter requires medical attention while taking part in an Upward Bound activity. Your signature indicates that you are aware of this policy, and that all medical statements on this form are true and complete.
Signature(s) of Parent(s)/Legal Guardian(s) (if applicant is under 18)

Use your mouse or finger to click and drag to sign the form Clear
Date

Month Day Year
mm-dd-yyyy

Family Information
How many people live in your household (including student(s) away at college)?

Please list the names of all people (including the student applicant and parent(s)/legal guardian(s)), along with their relationship to the applicant. If the person is not related but is currently living in the household, please write “unrelated.” If the person is neither attending school nor employed, please put “not employed.” For babies and preschoolers, please put N/A (not applicable) for school/employment boxes. If more space is needed, please attach an additional sheet.

	Name	Relationship to Student	Age	Name of School, College, or Place of Employment	Grade Level
1
2
3
4
5
6
7
8
9
10
11
12

Additional Sheet
Do you

Own your home Rent Living in Public Housing

Upward Bound Program Household Income Verification Sheet
Today's Date

Month Day Year
mm-dd-yyyy
TOTAL YEARLY HOUSEHOLD TAXABLE INCOME: AMOUNT
$______________
Student's Name

First Name Last Name
Your Signature (Parent)

Use your mouse or finger to click and drag to sign the form Clear
Your Printed Name (Parent)

First Name Last Name

Short Essays
For the Student (Applicant) to complete.
What activities do you currently participate in (sports, band, ROTC, church activities, work or other)
What has been your greatest accomplishment?
What are your college and career goals? What college do you want to attend? What do you think you want to major in in college? What do you want to be when you grow up?
The University of Dayton Upward Bound (UD-UB) has an intensive Year-Round Saturday Program and a six-week Summer Academy (which includes English, math, science, and test-prep courses). Why do you think you are ready to make the commitment to this program?
I certify that all of the information given by me to the University of Dayton Upward Bound (UD-UB) Program is true and complete to the best of my knowledge. I promise to provide whatever appropriate information is requested. I realize that any misrepresentation of false information on these forms will lead to withdrawal of any offer for my student to join the program, or to later disqualification of my student as a participant in the University of Dayton Upward Bound (UD-UB) Program.
Signature(s) of Parent(s)/Legal Guardian(s) (if applicant is under 18)

Use your mouse or finger to click and drag to sign the form Clear
Date

Month Day Year
mm-dd-yyyy
Signature of Student (applicant)

Use your mouse or finger to click and drag to sign the form Clear
Date

Month Day Year
mm-dd-yyyy