2024 TRIO Upward Bound Application

STUDENT INVOLVEMENT
Are you presently employed?

YesNo
How many hours per week do you work?
In what clubs, activities, or school and community organizations have you participated during high school? (music, drama, sports, UIL)
PROGRAM COMMITMENT
Student's Signature *

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Date
Parent's Signature *

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NAME OF YOUTH CAMP:
NAME OF CAMP PARTICIPANT: *

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH*

MonthDayYear
Date
SEX:
HEIGHT:
WEIGHT:
PARENT/GUARDIAN'S NAME: *

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN'S CELL PHONE:
Please enter a valid phone number.
PARENT/GUARDIAN'S EMERGENCY PHONE:
Please enter a valid phone number.
NON-PARENT EMERGENCY CONTACT NAME: *

First NameLast Name
NON-PARENT RELATION:
NON-PARENT 'S CELL PHONE:*
Please enter a valid phone number.
NON-PARENT 'S EMERGENCY PHONE:
Please enter a valid phone number.
DO YOU HAVE HEALTH INSURANCE?*

YESNO
PLEASE UPLOAD A COPY OF THE INSURANCE CARD.

Cancelof
NAME OF CARRIER:
If you selected "no" to having health insurance, skip this question.
POLICY NUMBER:
If you selected "no" to having health insurance, skip this question.
NAME OF PRIMARY INSURED:
If you selected "no" to having health insurance, skip this question.
Does the Camp Participant have any chronic or acute medical problems?*

YESNO
If yes, please explain:
List any allergies to food, pollen, or medicine:
List any medications being taken at present time:
List any other conditions we should be aware of:
List any dietary restrictions we should be aware of:
My child is a vegan or vegetarian.*

VeganVegetarianNeither
Parent/Guardian's Signature*

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Date

Waiver of Liability and Hold Harmless Agreement
Name of Parent or Legal Guardian of Participant*

First NameLast Name
Signature of Parent or Legal Guardian of Participant*

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I hereby grant permission for my son/daughter, First Name Last Name to participate in the University of North Texas Upward Bound Program, including its residential summer program and academic year program. I also give my consent for the following:
Parent/Guardian 1's Signature*

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Parent/Guardian 1's Email
example@example.com
Parent/Guardian 2's Signature

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Date
Parent/Guardian 2's Email
example@example.com
Should be Empty:

STUDENT INVOLVEMENT