San Jacinto College-North-UB-Application Form

Upward Bound Program Application

The information you give will be held in strictest confidence by our staff.

Applicant Information
Name*

First NameLast Name
Social Security Number
999-99-9999
Date of Birth

MonthDayYear
mm-dd-yyyy
Gender

MaleFemale
Are you a US Citizen?

YesNo
If no, Resident alien Card Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
(999)999-9999
Your Cell Number*
(999)999-9999
Your E-Mail Address*
example@example.com
Your Parent's Cell Number
(999)999-9999
Your Parent's E-mail Address
example@example.com
High School*
Grade*
Emergency Contact Name

First NameLast Name
Phone
(999)999-9999
This Person's Relationship to You

Ethnicity (This will NOT affect your acceptance into this Program) Will you, the parent, please indicate if your child is (Please check “yes” or “no” to all):

	Yes	No
Hispanic
American Indian
Asian
Black or African American
White
Native Hawaiian or Other Pacific Islander

I give my permission for my son/daughter to apply for admission into the Upward Bound Program at San Jacinto College. I agree to encourage him/her to participate in all Upward Bound activities, In addition, I as the parent, agree to participate and cooperate with any activity sponsored by the program. I also agree not to punish my son or daughter by limiting their participation in the program. I also agree to submit any and all documents needed so that my child may receive all the benefits that this program has to offer. I also certify that the information and documents submitted with this application, and in the future, will be accurate, to the best of my knowledge, and am aware that any false information could result in my child becoming ineligible for this program.
Parent Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Tell us a little about yourself, your family and friends
Name of High School
Expected Year of Graduation
School I.D. Number
Name of Your School Counselor

First NameLast Name
What goal do you have for yourself academically (high school diploma, college degree, etc.)?
Are you related to a member of the SJCN Upward Bound Program?

YesNo
If yes, who?
Are any of your friends members of the Upward Bound Program?

YesNo
If yes, who?

Who lives with you? Please list the names and ages of EVERYONE, including yourself, living in your home right now and state their relationship to you.

	Name	Relationship	Age
1
2
3
4
5
6
7

Do you and/or your family receive any benefits from the Texas Department of Human Services, and/or Social Security benefits?

YesNo
If so, please provide us with a letter from the Texas Department of Human Services or the Social Security Administration that lists the amounts and type of assistance you are receiving.

Cancelof
Do you participate in anything at school? Please list any extra-curricular activities in which you are involved (at school or in the community).
What do you do for fun? What are your hobbies (things you enjoy doing on your spare time)?
What kind of music do you like to listen to?
What kind of movies do you like to watch?
Do you have any special health problems? If so, please explain. A Doctor's note may be required.
Are you on a special diet? If so, explain
Do you smoke?

YesNo
If so, are your parents aware of it?

YesNo
Tell us about your parents:
Marital Status of Parent(s)

MarriedSeparatedDivorcedWidowed
Foster Parents

YesNo
Tell us about your Father
Father's Name

First NameLast Name
Is your father

LivingDeceasedRetiredOccupation
Employer's Name
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Highest grade your father completed in school

123456789101112
Where did he attend?
College?

YesNo
If yes, where?
Is he a College Graduate?

YesNo
If yes, where from?
Tell us about your Mother
Mother's Name

First NameLast Name
Is your mother

LivingDeceasedRetiredOccupation
Employer's Name
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Highest grade your mother completed in school

123456789101112
Where did she attend?
College?

YesNo
If yes, where?
Is she a College Graduate?

YesNo
If yes, where from?
Tell us about your brother(s) and sister(s)
Have any of your brother(s)/sister(s) attended or completed college?

YesNo
If yes, who?
Where
If more than one has attended, please list who and where:

Auto-Biographical Sheet
PLEASE TELL US ABOUT YOURSELF. Be sure you include any major occurrences, person(s) or place(s) that have contributed to your development. Minimum three (3) paragraphs.

Student Agreement
As a member of the Upward Bound Program at San Jacinto College North, I agree to
participate in the entire program and conduct myself in a way to bring credit to my
family, my community, my school, the Upward Bound Program, and myself.

I will abide by the rules and regulations set forth by the Upward Bound Program at San Jacinto College North the entire length of time that I am a member of Upward Bound.

I will not use alcohol or other drugs. This includes family events or parties, if I do partake in alcohol or other drugs while a student of the Upward Bond Program, I understand that I will be dismissed from the program immediately.

I agree to participate in all program activities; I understand that if I miss three (3) sessions without notifying the Coordinator or Director, I will be dismissed from the Upward Bound Program.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Parental Permission
Date

MonthDayYear
mm-dd-yyyy
I, {nameOf97}, give my permission for my son/daughter {main_name} to apply for admission into the Upward Bound Program. Furthermore, I agree to encourage him/her to participate in all Upward Bound activities. In addition, I as the parent, agree to participate and cooperate with any activity sponsored by such a program. I also agree not to punish my son or daughter limiting their participation in the Upward Bound Program. I also agree to support the Upward Bound Program by submitting any & all documents needed so that my son/daughter may receive all benefits/support necessary to better participate in the Upward Bound Program.
Name of parent/guardian

First NameLast Name
Signature of parent/guardian

Clear

Medical Consent
We hereby grant permission to the San Jacinto College North Upward Bound staff, with the advice of a health care professional to authorize emergency treatment or other medical or surgical treatment care necessary for the health and well being of my son/daughter. We also understand that the parent or guardian will be notified as soon as possible by Program staff and/or the attending physician or other personnel.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
EMERGENCY CONTACT

In case of an emergency, please give the following information:
Name of Person to Contact

First NameLast Name
Relationship to Student
Home Phone Number
(999)999-9999
Work Phone Number
(999)999-9999
Do you have any special dietary, medical or other special circumstances we should know about: (Please describe)

Agreement for Release of Records
Pursuant to the provisions of PL 95-380 (Family Educational Rights and Privacy Act of 1974), I hereby grant permission to:
Name of High School
To release a copy of Student a Permanent Record of:
Name of Student

First NameLast Name
Date of Birth

MonthDayYear
mm-dd-yyyy
Social Security Number
999-99-9999
Student I.D. Number
to San Jacinto College North-Upward Bound Program.

I understand that this record contains identifying data, grade records, attendance records, test scores, immunization records, and other pertinent information concerning this student. Parent or student may examine a copy upon request.
Signature (Parent's if under 18 years old)

Clear
Date

MonthDayYear
mm-dd-yyyy
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code