UHD Upward Bound Application

Upward Bound Application Form

General Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday*

MonthDayYear
Date
Age*
Grade*
Graduating Year*
Student Mobile Number*
Please enter a valid phone number.
Parent/Guardian Mobile Number*
Please enter a valid phone number.
What is total number of those currently living in your household?*
What is the primary language spoken at home?
Emergency Contact*

Student Citizenship
Citizenship Status*

US CitizenPermanent Resident Of The United States
Race/Ethnicity *

Student Information
Zoned School*
Attending School*
Other school*
Student ID
Student Essay Topics

A. Describe your neighborhood, mentioning how it looks, who lives there, what you like or dislike about it.

B. What do you hope to gain from your Upward Bound experience and what would you contribute to the UB program.

C. Tell us about a special circumstance which may have affected your performance in school and how you handled it. (Illness, family problems, peers, sports, etc.)
Student Essay

Select one of the three topics. Write a minimum of 300 words.0/700
By signing my name on the signature below, I certify that the information in this application is complete and accurate to the best of my knowledge. If accepted into the UHD ETS program, I will strive to continually improve my academic performance and maintain an active ETS participant.
Student Signature*

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Parent/Guardian Infromation
Parent/Guardian Information*
Work Phone Number*
Please enter a valid phone number.
Parent/Guadian Mobile Number*
Please enter a valid phone number.
Occupation*
TOTAL FAMILY INCOME FOR PREVIOUS YEAR *
NUMBER OF PEOPLE SUPPORTED BY THIS INCOME*
OTHER SOURCES OF INCOME: PLEASE INDICATE IF YOU RECEIVE ANY OF THE FOLLOWING (CHECK ALL THAT APPLY)
IS YOUR CHILD ON THE FREE OR REDUCED LUNCH PROGRAM AT SCHOOL?*
DO YOU OR YOUR SPOUSE HOLD A BACHELOR’S DEGREE?*
By signing my name on the signature line below:
- I certify that the information in this application is complete and accurate to the best of my knowledge. I understand that this information will be used to verify eligibility and to provide data in compliance with federal regulations. I also give my consent to the University of Houston Downtown Educational Talent Search program to obtain transcripts and any educational records that pertain to my child’s academic progress.
- I give permission to the University of Houston-Downtown Upward Bound
  Program to request and receive education records, test scores, transcripts, and other documentation for the above named
  participant.
- I authorize the staff of Upward Bound Trio Program to consent of medical treatment of such minor when I cannot be
  contacted to so consent; such medical treatment to include, without limitation, x-ray examination, anesthetic, medical, dental
  or surgical examination or treatment and general hospital emergency care. No prior determination of life-threatening
  emergency or danger of serious injury resulting from delay of treatment need be made under this authorization.
- I am in agreement with the goal of the Upward Bound Program to help
  motivate my son/daughter to complete school and enroll in a university, community college, or junior college.
  I understand that participation in Upward Bound activities is essential in order for the program to successfully help
  motivate my son/daughter. Therefore, I agree to encourage my son/daughter to:
- Attend school regularly and be on time for all classes
  Study or read at least one hour per day and complete all homework assignments.
- Attend Upward Bound and/or H.I.S.D. tutorials if his/her grades in English, Math, History or Science drops
  below a grade of 78
- Graduate from high school and enroll in the university, college, or junior college of his/her choice
- Attend Upward Bound workshops and meet with the Upward Bound counselor at least twice per semester
- I am or will be very supportive of my son/daughter’s educational and career goals and I agree to meet with and/or speak with the Upward Bound Program Advisor, at least twice per year to discuss my son/daughter’s progress
Parent Signature*

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What plans do you have for your son/daughter to attend college?
How can we at Upward Bound help you prepare your child for college?
How is your child's behavior in class?
Is your child on any medication?
Are there problems at home, i.e. divorce, deaths, separation, not getting along with siblings?
Parent Signature*

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Official Transcript - Transcript Request Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth
Grade Level
School
Student ID
Graduation Year
I give permission to the University of Houston-Downtown Upward Bound
Program to request and receive education records, test scores, transcripts, and other documentation for the above named
participant.
Parent Name

First NameLast Name
Parent Signature

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Submissions
Upload Transcript/Report Card

Upload the most recent transcript or report card available
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Portfolio Picture/Headshot*

NO filters, NO bathroom pictures. Please submit a clear headshot photo .
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Should be Empty:

Upward Bound Application Form