Texas Southern University-UB-Application Form

Texas Southern University
TRIO Upward Bound Program
3100 Cleburne Street ~ Houston, Texas 77004
Office: 713-313-7998 or 713-313-4207 ~ Fax: 713-313-7631
Student Application
To The Applicant and his/her Parent(s):

This application is our initial introduction to you and will play an important part in our consideration of you as an Upward Bound participant. It is essential that the entire application be completed before it is returned. Don't hesitate to add any information you feel is pertinent to your application. INCOMPLETE applications will not be considered for admission.

-Thank You

Opening Letter
The Texas Southern University Upward Bound Program is a federally funded educational outreach program designed to assist high school students move into a postsecondary educational experience. The thrust of the program is to prepare these students academically and socially to meet the challenges of postsecondary education. Participants in this program are potential first-generation college students and meet federal income guidelines.

The Upward Bound Program assists program participants through academic services, cultural enrichment activities, and individual counseling during the 9th, 10th, 11th, and 12th grades to become better prepared to enter and succeed in a postsecondary educational institution. The program also helps students acquire information regarding colleges (both in state and out of state), explore career options, and select appropriate majors to enter those careers.

The Upward Bound Program consists of two components: Summer and Academic Year. All services and activities are free.

ACADEMIC YEAR

The Academic Year component meets each Saturday between September and May (with appropriate holiday breaks) from 9:00 a.m. - 2:00 p.m. These sessions focus on tutoring, counseling, and test-taking skills. Several field trips are also included for cultural enrichment.

SUMMER

A six week residential intensive academic and personal development program comprises the summer component. Emphasis is on basic communication and mathematical skills, test-taking skills, career awareness, and social development skills. Activities include classes, special interest classes, cultural activities, recreational sports, and out-of-town field trip.

COST

There is no cost for students to participate in the Upward Bound Program. All program materials, services, and activities are free of charge to participants.

FOR MORE INFORMATION CONTACT

TRIO UPWARD BOUND PROGRAM
Texas Southern University
Fairchild Hall 147
3100 Cleburne Street ~ Houston, Texas 77004
Office: 713-313-7998 or 713-313-4207; Fax: 713-313-7631

Emergency Medical Treatment Consent Form
Child's Name

First NameLast Name
I hereby authorize the performance of medical examinations and necessary treatments (including tests, x-rays, medication, etc.) as may be deemed necessary by the attending physician to my child {childsName}. This consent shall be in effect for the Fall, Spring, and/or Summer component(s) participant is enrolled in the Upward Bound Program. If an emergency arises requiring immediate medical attention, the program administrators will attempt to reach me. If i cannot be reached, authorized the attending physician to act as his/her medical judgement dictates.
Signature of Parent/Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Release of Information Agreement
School or Test Center
Son/Daughter

First NameLast Name
{schoolOr} has my permission to release transcripts, test records, educational, and personal data on my son/daughter {sondaughter}, to the Texas Southern University Upward Bound Program so that it may be used in determining Upward Bound eligibility.
Student'sSignature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Financial Information
(To be completed by Parent or Guardian)

The personal information you give on the Upward Bound application is protected by the Federal Privacy Act. The information is required by the U.S. Department of Education to determine eligibility. Additionally, the Department of Education has the authority to gather information on all Upward Bound participants to monitor their progress. No one may see any information unless she/he works with or for the program or is specifically authorized to see the information. Individuals who violate the privacy act shall be subject to a fine of not more than $1,000 or imprisoned for not more than one year, or both, and shall be removed from employment.

LIST ALL SOURCES of parent(s)/legal guardian(s) monthly and yearly income. Income Verification is required (1040, SSI, AFDC)
Mother or Female Guardian's Name

First NameLast Name
Yearly Income $
Occupation
Number of years in school completed or degree
Monthly Salary
Source of Income or Place of Employment
Relationship to student if not natural mother
Phone Number at work
(999)999-9999
Father or Male Guardian's Name

First NameLast Name
Yearly Income $
Occupation
Number of years in school completed or degree
Monthly Salary
Source of Income or Place of Employment
Relationship to student if not natural father
Phone Number at work
(999)999-9999
Total Income for most recent tax year
Number of people support by this income
Estimated income for current tax year
Number of people supported by this income
Other sources of income

Social SecurityChild SupportDisabilityWelfareAlimonyUnemployment CompensationVeteran'sPension/RetirementOther
Total other income per month $

Family Information

	Name	Age	Do they live with you?
1
2
3
4
5
6
7
8

Give the name, address, and phone number of a relative or friend who does not live with you, but can be contacted in the event of an emergency. A telephone number is mandatory!
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
(999)999-9999
Relationship of this person to you
Certification: We certify that all information reported on this application is true, complete, and accurate to the best of our knowledge.
Parent or Guardian's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Emergency Information
Student Name

First NameMiddle InitialLast Name
Student ID #
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency, please contact/notify the following: (List at least two [2] people)
Name

First NameLast Name
Relationship to me
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
(999)999-9999
Name

First NameLast Name
Relationship to me
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
(999)999-9999
Signature of Parent/Guardian

Clear

Affidavit of Waiver
Parent or Guardian

First NameLast Name
Student

First NameLast Name
I, {parentOr150}, parent or guardian of {student}, am aware and agree that Texas Southern University, hereinafter called the University, its agents, officers, employees, and assignees are not, nor will they be, held personally or officially liable for any and all damages resulting from and all incidents, accidents, injuries, or claims which may arise out of my child's participation in the Upward Bound Program. I understand that he/she is participating in this program ad its program activities totally at his/her own risk. The University will not, in any circumstance, be held liable for any accidents, incidents, injuries, or claims which may arise out of such program activities, including but not limited to field trips, outings, tours, gatherings, and other activities.

I am also aware that this waiver does excuse the University for any negligent conduct that directly causes injury to my child.

Wherefore, I waive any and all rights that may arise to hold liable by any cause of action the University, its agents, officers, employees, and assignees in their official or personal capacity.

I give my child permission to participate in any program activities and/or field trips, throughout his/her tenure in the Upward Bound Program.
Signature of Parent or Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy