2026 TRIO Upward Bound Application

STUDENT INVOLVEMENT
Are you presently employed?
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
PARENT/GUARDIAN'S EMERGENCY PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
NON-PARENT EMERGENCY CONTACT NAME:

First NameLast Name
NON-PARENT RELATION:
NON-PARENT'S CELL PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
NON-PARENT'S EMERGENCY PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
DO YOU HAVE HEALTH INSURANCE?
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?
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.
Parent/Guardian's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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 Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian 1's Email
example@example.com
Parent/Guardian 2's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian 2's Email
example@example.com
Should be Empty:

STUDENT INVOLVEMENT

PROGRAM COMMITMENT

PERSONAL GUIDANCE & SOCIAL/CULTURAL/RECREATIONAL DESIRED:

Eligibility Verification

Waiver of Liability and Hold Harmless Agreement