318905-St. Mary's University-Judson ISD-UB-2025 Application Form-Stephen

Treadaway Hall, Room 375
One Camino Santa Maria St.
San Antonio, TX 78228-8589
upwardbound@stmarytx.edu
210-431-4252

Student Name:*

First NameMiddle InitialLast Name

Birth Date:*

mm-dd-yyyy

Are you a U.S citizen?:*

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

Gender:*

Ethnicity- Check all that apply:*

Student’s Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student’s Personal Email Address:*

example@example.com

Student’s School Email Address:*

example@example.com

Student’s Cell Phone Number:*

(999)999-9999

Name of Parent or Legal Guardian*

First NameLast Name

Specify their relationship to the student*

Parent or Legal Guardian’s Cell Phone Number:*

(999)999-9999

Parent or Legal Guardian Email Address:*

example@example.com

Preferred Language for Parent/Legal Guardian Communication:*

High School:*

School ID:*

Grade Level:*

Graduating Class of:*

Year

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

Both Mother and FatherMother OnlyFather OnlyIf other, please explain:

Has your mother (natural or adoptive) received a baccalaureate (4-year) degree from the U.S.?*

YesNo

Has your father (natural or adoptive) received a baccalaureate (4-year) degree from the U.S.?:*

YesNo

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

YesNo

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

YesNo

Are you experiencing, or at risk of, homelessness?*

YesNo

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

Do you work?*

YesNo

If yes, where do you work?*

The following statements concern your commitment to St. Mary’s University’s
Upward Bound program if selected to participate.

I will continue to be in the Upward Bound program through the summer after high school graduation, regardless of my level of participation.*

YesNo

I will commit to regularly attending Upward Bound’s summer sessions, academic year sessions, events, and activities through the summer after high school graduation.*

YesNo

I will attend individual advising sessions with Upward Bound staff and communicate with Upward Bound staff through the summer after high school graduation.*

YesNo

I will abide by all Upward Bound policies & procedures as stated in the Participant Handbook, along with any other written or verbal policies.*

YesNo

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

YesNo

I consent to Upward Bound obtaining my transcripts (and educational records that pertain to academic progress) from my high school, school district, and postsecondary educational institutions.*

YesNo

This information, protected by the Family Educational Rights and Privacy Act (FERPA), is necessary to determine eligibility for Upward Bound and helps Upward Bound and the U.S. Department of Education measure students' academic progress in high school and postsecondary education.

I grant the Upward Bound program permission to use my name, statements, and likeness without charge for promotional purposes in Upward Bound’s publications, advertising, social media, etc.*

YesNo

You 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/legal guardian portion of the application.

Student Signature*

Date*

mm-dd-yyyy

Upward Bound Student Application - JISD