Education Service Center Region 12 UB

Upward Bound Application Packet

2101 W. Loop 340
P.O. Box 23409
Waco, TX 76702

Site Coordinator for Killeen:
Delilah Fernandez
(254) 230-5118
E-Mail: dfernandez@esc12.net

The personal information contained in this application will remain with the Upward Bound program and is kept on file for the federal government (US Department of Education). Information will not be released without the written authorization of the applicant or the parent/guardian, if student is under 18 years of age. Please keep in mind that there are multiple parts of this application and all parts must be submitted to be considered for the program. If you have any questions, please contact the site coordinator.

New Student Application
(To be completed by student)
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Email Address*
example@example.com
School ID #
Social Security Number
999-99-9999
Name of High School
Grade
Gender

MaleFemale
Age
Date of Birth

MonthDayYear
mm-dd-yyyy

Ethnic Background (mark all the apply)

	Yes	No
American Indian/ Alaskan Native
Asian
Black/African-American
Hispanic/Latino/Mexican- American
Native Hawaiian or Islander
White/Caucasian
Other

Please specify if you selected "Other"
Are you a US Citizen?

YesNo
Are you a US Permanent Resident? (This is a non-US Citizen who has the right to live and work in the United States indefinitely).

YesNo
Permanent Resident Number
High School Courses (Check all that apply)

RegularPre-AP/AP/HonorsGifted & TalentedDual CreditIB
School Activities
Organizations
Sports
Are you a participant in another Upward Bound, GEAR UP, or other TRIO program?

YesNo
Employment

Not employedWeekends OnlyPart-TimeFull-Time
Hours per week
Career Aspirations: What career or type of job are you interested in?
Academic Aspirations

High School OnlyTechnical or Trade SchoolMilitaryAssociates Degree (2 yr)Bachelor's Degree (4 yr)Graduate School
Academic/Non-Academic Needs Areas

Career PlanningCollege InformationFinancial Aid/ScholarshipsClass SchedulingTutoringStudy SkillsPersonal CounselingACT/SAT PreparationProfessional EtiquetteLearning About Cultural DiversityTest-Taking SkillsSelf-ImageCommunication SkillsGoal Setting/Time ManagementMathematicsForeign LanguageScienceSocial StudiesEnglish (Reading & Writing)BusinessTSIDual Credit
Essay #1: Please write a brief description of yourself, your interests, and/or your values.
Essay #2: Please write a paragraph describing why you want to participate in the Upward Bound Program and what you hope to gain from the program.

Current Class Schedule

	Class Title	Teacher	Room Number
1.
2.
3.
4.
5.
6.
7.
8.

I attest that the information provided on this application is correct and true to the best of my knowledge.
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy

Parent Application
(To be completed by Parent/Guardian)

Mother or Female Guardian
Mother's Name

First NameLast Name
Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
(999)999-9999
Cell Phone Number
(999)999-9999
Does the student live with this parent?

YesNo
Primary Language Spoken in Household
Father or Male Guardian
Father's Name

First NameLast Name
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
(999)999-9999
Cell Phone Number
(999)999-9999
Does the student live with this parent?

YesNo
Primary Language Spoken in Household
Educational & Household Income Information

Please Note that the following information is mandatory and necessary in determining eligibility form the program.
1. Did the student's MOTHER graduate from college with a 4-year bachelor's degree?*

YesNo
2. Did the student's FATHER graduate from college with a 4-year bachelor's degree?*

YesNo
3. Number of people living in your household?*
4. What is your household's ANNUAL TAXABLE INCOME* for the previous year?*
Please note that Taxable Income is usually lower than Adjustable Gross Income which is located at the bottom of the first page of most tax forms. ANNUAL TAXABLE INCOME can be found on page 2 of most tax forms. Please contact the Upward Bound Coordinator if you have any questions or need assistance locating this information.
I attest that the information provided above is correct and true to the best of my knowledge.
Signature of Parent*

Clear
Date

MonthDayYear
mm-dd-yyyy

Consent for Release of Student Records
Consent for Release of Student Records
I authorize the staff of the ESC Region 12 Upward Bound Program to access academic and personal information in my/my student’s legitimate educational interest. This information may include but is not limited to: public assistance, free & reduced lunch documentation; standardized test scores (PSAT, STAAR, AP, SAT, ACT, TSI, GED); report cards; unofficial transcripts; official transcripts; attendance and disciplinary records; information about the status of post-secondary education admission/enrollment; financial aid documentation including Texas Common Application information, FAFSA pin information code, SAR, and financial aid award letters in accordance with The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99). I understand this information is essential in assisting me/my child in preparation for post-secondary education. I further understand all information received is for Upward Bound use only and is held strictly confidential.

I understand that these records may contain identifying data, grade reports, high school and future college transcripts, test scores, immunization records, and teacher evaluations. Parent or student may examine a copy upon request.

I understand that these records will only be used by the project on an individual basis. I also understand that compiled records on a group basis may include any and all of these records. Compiled information will be used to
meet federal regulations of program evaluation.

Furthermore, I give permission for Upward Bound to access and collect this information for a period of ten years or until I/my student successfully completes a program of post-secondary education. owever, if I choose to withdraw this permission, I can call the Program Director at 254-297-1127.
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. §1232g, and the Texas Public Information Act, Texas Government Code §552.001 et seq., are respectively federal and state laws providing for the review and disclosure of student educational records. ESC Region 12 Upward Bound will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student and parent (if applicable), except as authorized by FERPA.

Field Trip Form
UPWARD BOUND FIELD TRIP
Authorization for Student Participation

THIS FORM COVERS ALL FIELD TRIPS FROM
September 1, 2024 - August 31, 2025

****Parents, please complete all of the following information:****
Student's Name

First NameLast Name
Name of Parent/Guardian

First NameLast Name
Phone Number
(999)999-9999
A. Parent/Guardian Permission
I understand that my son/daughter is not required to attend this ESC Region 12 field trip. I give permission for participation in the activity. I agree to release Education Service Center Region 12 and its officials, officers, and employees from liability for any and all claims of injury which might occur while my son/daughter is participating in this field trip activity.

B. Emergency Medical Authorization
Should a medical emergency arise while my son/daughter is participating in this activity, I will be notified at the above number in order to approve medical treatment. In the event that I or one of the emergency contacts listed below cannot be reached, I give permission for immediate treatment as required in the judgment of the attending physician. I understand and agree that I will be responsible for the cost of such treatment.
Emergency Contact

First NameLast Name
Phone Number
(999)999-9999
Emergency Contact

First NameLast Name
Phone Number
(999)999-9999
Name of Insurance Company
Group/Policy Number
Allergies/Special Health Considerations
Signature of Parent/Guardian*

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

Upward Bound Medical Form
Student's Name

First NameLast Name
Student's Email
example@example.com
Date

MonthDayYear
mm-dd-yyyy
Is the student allergic to any medications?

YesNo
Describe any medical problems UB should be aware of, such as asthma, allergies, or other medical conditions:
Does the student use an inhaler?

YesNo
Does the student use an epi-pen?

YesNo
Is the student currently under a doctor’s care?

YesNo

Is the student currently taking any prescription medications or long term medications?

	Name of Drug	Dosage	Purpose
1.
2.
3.

If needed, is UB authorized to administer any over the counter medications?(Headache medication, Pepto-Bismol, Benadryl)

YesNo
Briefly describe any limitations on the student’s physical activity:
Please mark any foods that your student is allergic to and or should avoid because of dietary restrictions:

Dairy (milk, ice-cream, cheese, etc.)SoyBerriesPeanutsChocolateYeastEggsGarlicChiliTomatoesSesame SeedsCornOranges/JuicePorkPistachiosPine NutsApplesGrapefruit/ JuiceFish Tree nuts (Almonds, Walnuts, etc.)Shellfish (shrimp, lobster, crab, etc.)Wheat/gluten/OatsPineappleBeans/LegumesOnionsKiwiSunflower SeedsSpinachChickenBeefRicePotatoesCoconutOther
**Students are ultimately responsible for monitoring their own diet
Signature of Parent/Guardian

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

Consent to Publication & Photo Release Form
Consent to Publication & Photo Release Form
For Education Service Center Region 12

I hereby give permission for my child, {studentName}, to be videotaped and/or photographed during educational activities with the Upward Bound program of the Education Service Center Region 12 for the duration of the student’s participation in Upward Bound.

I understand that my child will be identified by his/her first name only. The name of the class, school and city in which my child is located may be identified during the videotaping and/or photography or in any corresponding reproductions in publications and the Internet.

I further understand that these videotapes and/or photographs are property of the Education Service Center Region 12, 2101 W. Loop 340, Waco, Texas 76712. The videotapes and/or photographs will be used only to explain Education Service Center Region 12 programs and services, and/or to illustrate teacher instruction activities during professional development events. Publication purposes include permission and consent to reuse, disseminate, copyright, print, reproduce, publish and republish, for any commercial, advertising and public purposes.

I hereby release and discharge the Education Service Center Region 12 staff from any and all claims and demands arising out of or in connection with the use of any of the foregoing, including defamation, invasion of privacy or violation of any statutory right.
Student Name

First NameLast Name
Signature of Parent or Guardian*

Clear
Date

MonthDayYear
mm-dd-yyyy

Upward Bound Parent / Student Contract
Upward Bound Parent / Student Contract
Acceptance into the Upward Bound Program brings with it several responsibilities for both students and parents.
PLEASE REVIEW CAREFULLY THE UPWARD BOUND HANDBOOK AND THE FOLLOWING CONDITIONS FOR PROGRAM PARTICIPATION:

The student pledges:
1. To participate in the summer session each year, including attending all classes and special activities. Summer participation may be optional for some students depending upon budgetary limitations.

2. To participate in the academic program during the school year by attending tutoring sessions, attending Academic Saturdays, meeting with UB mentor, and completing assignments.

3. To show continued individual effort in regard to school attendance, citizenship, and scholarship.

4. To participate in special activities, trips, meetings, and events sponsored by Upward Bound.

5. To fulfill commitments made regarding the attendance of activities, trips, meetings, and events sponsored by Upward Bound. Failure to do so will result in administrative action.

Discipline:
In order to maintain a positive atmosphere whereby each student can achieve maximum academic and social development while enrolled in Upward Bound, all participants must conduct themselves in an orderly and respectful manner at all times. Therefore, they must pledge themselves to the following:

1. To respect all teachers, tutors, tutor advisors, and members of the Upward Bound staff. (Failure to do so may result in immediate dismissal.)

2. To follow all rules and regulations as outlined in Upward Bound school year and summer handouts.

3. To come to class and tutoring sessions prepared to engage in serious academic study.

Parent Responsibilities:
1. To attend scheduled parent meetings and student conferences as necessary.

2. To cooperate with the Upward Bound administration in resolving problems and conflicts regarding his/her child while in the program.

3. To provide transportation for your student as needed in support of your child’s participation in the Upward Bound program.

Probationary Period:
The probationary period for an Upward Bound student is 60 days. During this period, if a student fails to actively participate in every aspect of the program, he/she will be dropped from the program at the close of the probationary period. Students are not eligible for stipends during the probationary period.

The student and parent hereby acknowledge having read and comprehended the “Upward Bound Parent/Student Contract” and the “Upward Bound Student Handbook” and are in agreement with and pledge to abide by its provisions. A written copy is available through the website www.esc12.net/upwardbound
Signature of Student*

Clear
Date

MonthDayYear
mm-dd-yyyy
Signature of Parent*

Clear
Date

MonthDayYear
mm-dd-yyyy

Applicant Checklist
Applicant Checklist
Before returning this application form, please review the Applicant Checklist. All supplementary documents must be submitted to be considered for admission. Incomplete applications will not be evaluated.

Part 1 - Student Application Packet
- New Student Application
- Teacher/Counselor Recommendation Form
- Current Report Card
- Current Transcript
Part 2 - Parent Application Packet
- Parent Information Sheet
- Consent for Release of Student Records
- Upward Bound Field Trip Form
- Consent to Publication & Photo Release Form
- Student/Parent Contract
Part 3 Upward Bound Teacher Recommendation Form

Student Applicants will need to give the following link to their teacher to complete the Upward Bound Teacher Recommendation form. Once the teacher completes the form it will automatically be sent to the Upward Bound Coordinator.

https://botform.compansol.com/202814576850964

Completed application should be returned to your ESC Region 12 Upward
Bound Coordinator.

UB Site Coordinator-Killeen
dfernandez@esc12.net
(254) 230-5118

Consent for Release of Student Records

Consent to Publication & Photo Release Form

Upward Bound Parent / Student Contract

Applicant Checklist