University Of Texas-San Antonio-Southside-UB-Application Form

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University of Texas-San Antonio

TRIO Upward Bound

Dear Applicant,

Thank you for your interest in the TRIO Upward Bound Program at the University of Texas at San Antonio. TRIO Upward Bound is designed for students with academic potential who need additional preparation and motivation to succeed in high school and later, in college. TRIO Upward Bound Program is a year-round program. The program provides on-going academic preparation, counseling, and enrichment activities.

Eligibility to participate in the program is determined individually. However, each applicant must meet basic eligibility requirements set forth by the federal government, that require neither parent to have a four-year college degree and family’s income level verification. Our Upward Bound Program serves a limited number of students. Therefore, it is important that you complete your application as soon as possible. When space is not available, an applicant may be referred to our waitlist for later consideration.

There is a five-week summer program offered first to students who have participated in the year-round portion, and have sufficient summer attendance and satisfactory grades. The summer program is designed to simulate the experience of attending college. The summer program focuses on academics and enrichment activities.

Below you will find instructions for completing the application process. Applications are accepted and reviewed year-round but students are only accepted if space permits. Once your application is received, you will be notified of your application status. We look forward to you being a part of our family!

All of the information contained in this application will remain confidential by the UTSA Upward Bound staff in determining the eligibility of a student. Please return this application to your child’s school guidance counselor according to the deadline determined by the Program Director. Students selected for an interview will be contacted by our office.

The University of Texas at San Antonio Office

1.308 Buena Vista Bldg.

UTSA Downtown Campus San Antonio, TX 78207

Sal Acosta

Retention Specialist, Upward Bound

PH: 210-241-8771 (call or text)

Email: Salvador.acosta@utsa.edu

Jay Smiley

Director, Upward Bound

PH: 210-872-4739

Email: jay.smiley@utsa.edu

Important Parent Note: UB is a free, academic support program provided through funding from the U.S. Department of Education. Students will have participation objectives, but the program will work to balance other high school commitments such as sports team involvements, other academic interests, and community service.

Academic Information
Middle School:*
High School:*
Current Grade*
Current weighted Grade Point Average
Current Unweighted Grade Point Average
Current Guidance Counselor

First NameLast Name
School ID Number*
Are you taking ESOL classes (select one)*

YesNo
Primary Language Spoken at Home*
Does Student Currently Have an IEP on file*

YesNo
If yes, please attach copy of IEP

Cancelof

Parent/Guardian Information
Must be completed by a Parent or Guardian:
Student Name:*

First NameLast Name
Parent/Guardian 1
Name*

First NameLast Name
Relationship to Student*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
Are you the Primary Contact?*

YesNo
Email*
example@example.com
Occupation*
Work Phone*
(999)999-9999
Home Phone Number*
(999)999-9999
Parent/Guardian 2 - Complete If Applicable
Name

First NameLast Name
Relationship to Student
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
(999)999-9999
Are you the Primary Contact?

YesNo
Email
example@example.com
Occupation*
Work Phone*
(999)999-9999
Home Phone Number*
(999)999-9999
In case of an emergency, parent(s)/guardian(s) or the two alternate persons listed below should be contacted:
ALTERNATE EMERGENCY CONTACT
Alternate's Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Home Phone*
(999)999-9999
Cell Phone:*
(999)999-9999
Relationship to Student*

Student Photo Release
I, {main_name}, hereby grant The University of Texas at San Antonio (“UTSA”) the absolute and irrevocable right and permission, to record my image, likeness and/or voice on a video, audio, photographic, digital, electronic or any other medium (“Recording”) in which I may be included with others, to copyright for same; to use, reuse, alter, edit and publish the same in whole or in part in any and all media including but not limited to use on the world wide web, now or hereafter, and for any purpose whatsoever that UTSA deems appropriate including but not limited to, exhibition, education, illustration, promotion, art, advertising and trade, and if appropriate, to use my name and pertinent education and/or biographical facts as UTSA chooses.

I hereby release and discharge UTSA, its governing board, officers, representatives, employees and agents from any and all claims and demands for compensation arising out of or in connection with the use of the Recording.

I hereby release and discharge UTSA, its governing board, officers, representatives, employees and agents from any and all claims and demands arising out of or in connection with the use of the Recording, including without limitation any and all claims for libel or invasion of privacy.

I am of full age and have the right to contract in my own name. I have read the foregoing and fully understand its contents. This release shall be binding on me and my heirs, legal representatives and assigns.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Printed Name*

First NameLast Name
Printed Name*

First NameLast Name

Certification/Release of Information
I certify that the information I have provided on this application is, to the best of my knowledge, true and correct.  Furthermore, I understand that by applying for this program, I authorize the Upward Bound Program to obtain records or data pertinent to my participation from other sources (including, but not limited to, Financial Aid, Student Disability Office, and Office of the Registrar), and to release information as required by law or the terms of the Upward Bound Grant, to the grant-funding agency of the federal government**. I further authorize Upward Bound Staff to discuss issues related to my academic progress with other high school faculty, university faculty, and staff for the purpose of coordinating academic and personal support services.
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
** The University of Texas at San Antonio Upward Bound (UB) is asking you to provide information which includes private information under state and federal law. UB is asking for this private information so that we can process your application for your admission to our program.  This information will be used to evaluate your application for admission to determine whether you are a suitable candidate for admission into our program.  You are not legally required to provide the information UB is requesting, and you may refuse to provide some or all of the information requested.  However, UB may not be able to consider your application if you do not provide sufficient information.  With some exceptions, unless you consent to further release of private information, access to this information will be limited to the individuals involved in our admission process (including the Financial Aid, Student Disability Office, and Office of the Registrar) and the advisors and clerical personnel of the program.  However, federal and state laws do authorize release of private information without your consent to: school officials who have legitimate educational interests in the information; the U.S. Dept. of Education for the purposes of program compliance, audit or evaluation; a court, grand jury, or state or federal agency, if the information is sought with a subpoena; appropriate persons in connection with an emergency, if necessary to protect your health or safety or the health or safety of others; if required by a court order, or permitted by other state or federal law.

PRIVACY ACT

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Upward Bound Program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Upward Bound program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. The information that is collected on this form will be retained in the program files and may be released to the National Student Clearinghouse or other UTSA department officials in the performance of their official duties.

Upward Bound is a federally funded program by the U.S. Department of Education in cooperation with

The University of Texas at San Antonio.
Student Signature*

Clear
Printed Name*

First NameLast Name
Printed Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
How did you learn about TRIO Upward Bound?*
Which of the following services may be of interest and/or benefit to you? (Please check all that apply). *

Writing SkillsReading SkillsMathematicsCommunication SkillsAcademic AdvisingSupport & Guidance to take challenging college preparation coursesAssistance in English proficiencyCareer Exploration/EmploymentExploration of careers in Math & ScienceCollege Admissions assistance & awarenessACT/SAT Preparation and RegistrationScholarship and Financial Aid AdvisingFinancial Literacy (i.e. money management)Study Skills/Test-Taking SkillsPeer mentoringSelf-esteem & social skills developmentPeer mentoringCommunity ServiceCultural EventsUniversity Campus visitsSupplemental InstructionTutoring in: (specify below)
Tutoring in:*
What academic challenges are you facing? *
Have you been involved in any other grant funded or TRIO Programs? Please check all that apply:*

Educational Talent SearchGear UpUpward BoundUpward Bound Math and ScienceNot ApplicableOther
Why do you want to join UB? *
As an UTSA Upward Bound participant, you are eligible to earn a stipend during the Academic year and/or Summer Academic Program in addition to the virtual and in-person services offered by the UTSA Upward Bound Program by maintaining at least a 2.5 GPA in high school classes, have active attendance at Saturday workshops, college exam boot camps, career workshops, meeting retention specialist for advising sessions, utilizing the Photostudy Tutoring App, completing the On Track modules, and making progress in the Rosetta Stone: Learn Language application. Senior participants should complete Transition to College Checklist prior to May/June 2022 graduation.
Participant Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Is the participant covered by any medical insurance?*

YesNo
If yes, please complete the following:

If no, please type N/A
Name of Insurance Company*
Insurance Policy Number*
Name of Family Physician*
Office Telephone*
(999)999-9999
As the Parent/Legal Guardian, I hereby authorize over the counter medication (Ibuprofen, Pepto Bismol, etc) to be dispensed to my child as needed.*

YesNo

Please list any personal or family medical history that may be of importance to our records, including allergies and physician prescribed medicine that student is currently taking:*

	List Medication/Medical History	Allergies	Allergic Reaction
1
2
3
4

As the parent/guardian of the above named participant, I hereby authorize the program director and his/her authorized staff to furnish medical diagnostic and/or authorize the medical and/or surgical treatment of my child as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the child. The University of Texas at San Antonio and its officers, regents and employees shall not be liable in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise out of such diagnosis, treatment or surgery to the extent allowed by law, except as provided for through the group medical insurance plan if the student contracted for the same prior diagnosis, treatment or surgery. Furthermore, the University does not assume any financial or other responsibility, but wishes to provide the best services possible in case of emergency.

In case of serious illness/accident I will be notified immediately, but if I cannot be reached, necessary interim emergency care may be provided by a physician/nurse.
Parent/Legal Guardian's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Person to call in case of emergency:*

First NameLast Name
Phone to call in case of emergency:*
(999)999-9999