University Of Texas-Rio Grande Valley-Edinburg-UB-Application Form

Student Application
Name*

First NameMILast Name
Date of Birth*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Phone*
(999)999-9999
Parent Phone *
(999)999-9999
Email*
example@example.com
High School*
Grade Classification*
MaleFemale
RecommendedDistinguished
High School ID#:*
We use your student ID to request your report cards, transcripts and STAARS scores from your school counselors.
YesNo
HispanicAmerican IndianBlackAsianWhiteOther
YesNo
A#*
YesNo
If yes, please specify*
YesNo
YesNo
SMLXLXXLXXXL
YesNo

Extra-Curricular Activities*

Rows	Activity (Band/Sports/Clubs)	In what capacity?	Do you meet on Saturday?
1
2
3
4
5

Individuals with disabilities wishing to acquire this application in an alternative format should contact the Upward Bound office at (956) 665-2596.

The University of Texas Rio Grande Valley is committed to providing equal opportunity to all persons seeking employment, or access to its programs facilities, or services without regard to race, religion, color, sex, disability, age, veteran status, national origin, or sexual orientation.
Student Signature*

Clear
Date*

MonthDayYear
Date
STUDENT PERSONAL STATEMENT Please share a little about yourself and explain how the Upward Bound Program can help you reach your educational goals. Please write at least 250 words for your application to be considered. :*
- Student name:*
  
  First NameLast Name
- School:*
- Grade:*
- Name of Mother/Legal Female Guardian: *
  
  First NameLast Name
- Mother/Legal Female Guardian mailing address: *
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Mother/Legal Female Guardian home phone number: *
  (999)999-9999
- Mother/Legal Female Guardian cell phone number: *
  (999)999-9999
- Mother/Legal Female Guardian employer/occupation:*
- Mother/Legal Female Guardian work phone number:*
  (999)999-9999
- Mother/Legal Female Guardian e-mail address:*
  example@example.com
- Name of Father/Legal Male Guardian:*
  
  First NameLast Name
- Father/Legal Male Guardian mailing address:*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Father/Legal Male Guardian home phone number:*
  (999)999-9999
- Father/Legal Male Guardian cell phone number:*
  (999)999-9999
- Father/Legal Male Guardian employer/occupation:*
- Father/Legal Male Guardian work phone number:*
  (999)999-9999
- Father/Legal Male Guardian e-mail address:*
  example@example.com
- Mother and FatherFather onlyMother onlyLegal GuardianOther
- Name of legal Guardian if the student does not live with a parent*
- YesNo
- Total Number in household*
- INCOME INFORMATION Please attach a SIGNED copy of your current U.S. Income Tax Form/income statement (if you do not file) in order to verify annual taxable income.*
  
  Cancelof
- Income Information Page 2
  
  Cancelof
- BIRTH CERTIFICATE / SSN please attach a scan or photo of your Birth Certificate and SSN card. TRIO programs are federally funded and have strict eligibility criteria. The Birth Certificate and SSN cards are used to verify your citizenship or legal residency status, age and identity. SSNs are used to track your progress through educational systems in the future. We are required to follow FERPA and other federal privacy laws and will keep all your personal information confidential and use only for official, authorized purposes.*
  
  Cancelof
- PARENT CERTIFICATION
  My son/daughter has permission to apply for the UTRGV UB program. If selected he/she will be allowed to participate in all phases to the program. This includes nine (9) Saturday classes during the academic school year and a six (6) week summer program during their Sophomore, Junior and Senior years of high school. I also hereby certify that my family income and all information as stated in the application for participation in the UB program is true and correct.
  
  WEB RELEASE
  I give permission to the UTRGV UB program to display photo of myself and/or my son/daughter on the UB newsletter and other publicity materials.
  
  HB 1922 RELEASE
  With few exceptions, you are entitled, on your request, to be informed about the information UTRGV collects about you. Under sections 552.021 and 552.023 of the Texas Government Code, you are entitled to received and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have UTRGV correct information about you that is held by us and that is incorrect,
  in accordance with the procedures set forth in The University of Texas System Business Procedures Memorandum 32. The Information that UTRGV collects will be retained and maintained as required by Texas records retentions laws (Section 441.180 et/ seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
  
  RELEASE OF STUDENT INFORMATION
  (In compliance with the family education rights and privacy act of 1974) I request that a transcript of my grades, and any other records required, be released from my High School and made available upon request to UTRGV or the UB program for enrollment and/or financial aid purposes.
  
  I certify that the information provided on this form is true and complete to the best of my knowledge.
- Parent Signature *
  
  Clear
- Date*
  
  MonthDayYear
  Date
- Student Name*
  
  First NameLast Name
- Student ID*
- High School*
- I hereby, give permission for The University of Texas Rio Grande Valley Upward Bound Program to obtain any and all of my academic records including high school Student Permanent Records and all future college transcripts and records.
  
  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 regulation of program evaluation.
  
  None of my identified, individual records will be released to any person, corporation, organization, nor present or future employer.
- Student Signature *
  
  Clear
- Date*
  
  MonthDayYear
  Date
- Parent Signature*
  
  Clear
- Date*
  
  MonthDayYear
  Date
- Parent Signature*
  
  Clear
- Date*
  
  MonthDayYear
  Date
- Teacher Recommendation (Required)
  
  As part of the Upward Bound application, we require one recommendation from a core subject teacher (English, Math, Science, or Social Studies).
  
  Please follow these steps:
  1. Identify a teacher who knows you well and can speak to your academic abilities.
  2. Ask them if they would be willing to complete a recommendation form on your behalf.
  3. If they agree, enter their full name and school email below.
  4. Once submitted, we will send them a link to the recommendation form directly.
- Teacher's Full Name*
  
  First NameLast Name
- Teacher's Email*
  example@example.com

Student Application