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TRIO UPWARD BOUND - ALAMOGORDO HS

NEW PARTICIPANT APPLICATION
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STUDENT'S INFORMATION
Student's First Name *
Middle Name
Last Name *
Social Security Number *
School ID Number *
Gender *
Citizenship Status *
PLEASE UPLOAD Proof of Citizenship (Image of Birth Certificate, Passport, or SS Card) *
Ethnic (Hispanic) (Y = 1 ; N = 2) *
White (Y = 1 ; N = 2) *
Black or African American (Y = 1 ; N = 2) *
American Indian/Alaskan Native (Y = 1 ; N = 2) *
Asian (Y = 1 ; N = 2) *
Native Hawaiian or Other Pacific Islander (1 = Yes ; 2 = No) *
Physical Address *
Physical Address 2
Physical Address City *
Physical Address State *
Physical Zip *
Mailing Address 1
Mailing Address 2
Mailing Address City
Mailing Address State
Mailing Address Zip
Student's Mobile Phone Number *
Student's Email Address *
Student's T-Shirt Size *
Student's Entry Grade Level *
Student's Entry GPA *
Expected High School Graduation Year *
Please Upload Student's Most Current Transcript or Progress Report
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PARENT'S INFORMATION:
Who does the applicant live with? *
If "Other" please explain:
Father's Full Name *
Father's Phone Number *
Father's Email Address *
What is the Father's highest level of education? *
Signature Certifying Father's Educational Level (if parent is not accessible, the other parent or guardian can sign.) *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Mother's Full Name *
Mother's Cell Phone *
Mother's Email Address *
What is the Mother's highest level of education? *
Signature Certifying Mother's Educational Level (if parent is not accessible, the other parent or guardian can sign.) *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

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Household and Income Information:
How many people live in the household? *
What was your Gross Income (before deductions) last year? *
What was the household's filing status during the most current filing year? *
Please upload proof of income (most current IRS forms, Social Security Benefits Statement, SNAP Benefits Statement) *
Upload Proof of Income - additional pages.
Parent's Signature Verifying Gross Income Level. *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

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STUDENT'S MEDICAL INFORMATION:
Medical Insurance Carrier
Medical Insurance Member Number
Medical Insurance Group Number
Medicaid Number
Primary Care Physician
List all medical conditions we need to be aware of.
List any life-threatening allergies.
Please list any medications that the student is taking.
Emergency Contact's Full Name *
Emergency Contact's Relationship *
Emergency Contact's Phone Number *
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Signatures:

By signing this application, you are verifying that all the information provide on this application is true and accurate.

Your digital signature will serve as an actual signature.
Student's Signature *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Parent's Signature *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number: