UNIVERSITY OF TEXAS AT SAN ANTONIO PARTNERSHIP

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							                                 UNIVERSITY OF TEXAS AT SAN ANTONIO-HEAD START PARTNERSHIP
                                    APPLICATION FOR UTSA HEAD START SUMMER INSTITUTE 2010
             UTSA Head Start
             Summer Institute




Instructions:             1. Print in ink and answer ALL questions.
                          2. Include official “sealed” transcripts from EVERY college/university attended.
                          3. Include a current degree plan with the name and phone number of your academic advisor.
                          3. Forward completed application (NOT INCLUDING SUPERVISORY FORM) and all supporting
                          documents by January 2, 2010 to:

                                 ATT: Sophia M. Ortiz, Summer Institute Program Coordinator
                                 The University of Texas at San Antonio
                                 501 W. Durango Blvd. – MTNB 2.260
                                 San Antonio, Texas 78207

                          Incomplete applications will not be considered. If you have any questions or need help
                          completing the application or obtaining supporting documents please call Sophia Ortiz at (210)
                          458-2692 or email Sophia.Ortiz@utsa.edu . We’re here to help you achieve your goals!

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Name of Applicant ___________________________ ____________________________                                                     _____
                                               Last                                First                                         MI.

_______________________________________ _____________________________ __________
                                 Address                                                   City/State                        Zip

Home Telephone (                    )____________________Work Telephone (                        ) ______________________

Other Telephone (                   ) ____________________

Birth date____________________________                              Social Security #_________________________

Maiden Name_______________________                                  Email address __________________________

At which Head Start Center are you employed? (Check one)

         [      ] AVANCE                                        [     ] Texas Migrant Council

         [      ] Community Action, Inc.                        [     ] Family Services

         [      ] SAISD                                               [   ] EISD                                [   ] Other

What is your title/position? ______________________________ Hours Worked______________




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Do you have original college transcripts? Yes or No


Have you been assessed for the state requirement of the Texas Success Initiative? Yes or No
If Yes, please check the test taken and enter the date of the test:

 ______ Texas Higher Education Assessment (THEA) or the “Quick THEA” taken ______________
 ______ ACCUPLACER taken _______________
 ______ COMPASS taken __________________
 ______ ASSET taken _____________________


If you have not yet tested and would like to do so, UTSA Testing Services offers the tests listed above on a
scheduled basis at both the downtown and 1604 campuses. Please call (210) 458-4125 for times, dates, and
registration.

There are some exemptions to the TSI and they can be found on the following UTSA web site:
http://www.utsa.edu/success/exempt.cfm

List ALL the Colleges/Universities you have attended.

Name of College                                      Location                               Dates




What is your educational objective? (Choose one)
[ ] Complete an (A.A.) Associate of Arts Degree or an (A.A.S.) Associate in Applied Sciences
Degree in ____________________________________.
[ ] Complete a (B.A.) Bachelors of Arts Degree or a (B.A.A.S.) Bachelor of Applied Arts and
Sciences Degree in _____________________________________. (Note: the B.A.A.S. degree
program requires that students have already received an A.A.S. degree.)

Are you currently enrolled in college? If so, where?________________________________
List the courses you enrolled in for Fall 2009_____________________________________
________________________________________________________________________
If you intend to take courses in the Spring of 2010 please list them____________________
_________________________________________________________________________
How many hours do you need to complete an A.A. or an A.A.S. Degree? ______________
How many hours do you need to complete a B.A. or a B.A.A.S. Degree? ______________

While in college, have you ever been placed on Academic probation? Yes or No
If so, are you currently on academic probation? Yes or No

Have you ever failed to successfully complete a course? Yes or No


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If you answered yes, please explain: _________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Have you ever been dismissed from a college or university due to grades or disciplinary action?
Yes or No

Will you be working in a Head Start classroom during the summer months? Yes or No
Will you be travelling from out-of-town to San Antonio for the 2010 Summer Institute? Yes or No
If Yes, will you need (housing) accommodations? Yes or No


Do you have any obligations (family, work, etc.) that could prevent you from attending classes
this summer? Please explain:
________________________________________________________________________________
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Tell us why you would like to participate in the UTSA Head Start Summer Institute 2010:

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________________________________________                 ___________________________
Applicant Signature                                      Date




Thank you for applying to the UTSA SUMMER INSTITUTE 2010. If you are selected to
participate, we will assist you with the formal application process for admission to UTSA.




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