St. Mary's University-SA ISD-UB-2022 Application Form

Name:*

First NameLast Name

Pronouns:*

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student's Email:*

example@example.com

Student's Phone Number:*

(999)999-9999

Parent's Cell Phone Number:*

(999)999-9999

Parent's Email

example@example.com

Birth Date:*

mm-dd-yyyy

High School:*

Grade Level:*

9th10th11th12th

Graduating Class of:*

Overall Grade Point Average:

Class Rank:*

of:

Place of Birth:*

Street Address

Street Address Line 2

CityState / Province

Country of Birth:*

Are you a U.S citizen:*

YesNo, but I am a permanent residentNo, I am NOT a U.S citizen or a permanent resident

If you are a permanent resident of the U.S; what is your U.S Citizenship and Immigration Services (USCIS) Number (i.e. Alien Registration Number or Alien Number)?:

(The following information is requested for government reporting purposes only and is not considered in determining eligibility for participation.)

Will you require any special accommodations for a physical or other limitation(s):*

YesNoNot Sure

If yes, please explain:

Sex:*

MaleFemale

Ethnic/Racial Background- Check all that apply:*

Is there an ARD or IEP report on file for you at your school?*

YesNo

Have you passed all sections of the STAAR?:*

YesNo

If no, what subject was not passed?

Are you at risk of not passing a class?*

YesNo

Has your mother received/earned a baccalaureate/ 4-year degree from the U.S?*

YesNo

Has your father received/earned a baccalaureate/ 4-year degree from the U.S?*

YesNo

Which parent do you regularly reside with and receive support from?*

Both Mother and FatherMother OnlyFather OnlyNeither Mother nor Father

Do you (the student) have children?:*

YesNo

Are you an orphan, in foster care, or a ward of the court?:*

YesNo

Are you an emancipated minor or do you have a court-appointed legal guardian?:*

YesNo

Are you homeless or at-risk of homelessness*

YesNo

Do you work?*

YesNo

If yes, where?

The following statements concern your commitment to the program if you are selected to participate in the St. Mary's University Upward Bound program.

I understand if I am selected for the Upward Bound program that I will continue to be in the program until the summer after high school graduation, regardless of participation.*

YesNo

I will make a commitment to attend the Summer sessions, Academic Year sessions, and activities on a regular basis until high school graduation.*

YesNo

I will attend 1:1 advising with my Student Success Specialist or STEM Coordinator and stay in communication with the Upward Bound staff until the summer after high school graduation.*

YesNo

I will submit my progress report and report card every semester and understand that this is only to help me increase my academic achievements.*

YesNo

I will commit to attending college as a full-time student immediately following high school graduation and will remain enrolled until college graduation.*

YesNo

I will abide by all policies and procedures, including but not limited to dress code.*

YesNo

You have completed the student portion of the St. Mary's University Upward Bound application; to be considered for our program please submit this form and have your PARENT or LEGAL GUARDIAN complete and submit the parent portion of this application.

Signature:*

Date:*

mm-dd-yyyy

Upward Bound Pre-College Program Student Application - SAISD