Funded by U.S Department of Labor Grant
Application Packet
Thank you for your interest in the Clinical Laboratory Initiative to Mentor Baccalaureate Students (CLIMBS) coordinated by the University of Texas Medical Branch at Galveston. The program is funded by a Department of Labor Grant with specific guidelines to be used in the administration of funds for in-state tuition, books and fees. Below you will find a summary of the information needed to qualify and meet the standards set forth by the grant guidelines. A full narrative can be found in the CLIMBS Program Description. Priority admission will be given to the following:
- Unemployed workers (27 weeks)
- Unemployed (>27 weeks) United States Armed Forces Veteran & Spouses
- Underemployed workers (>27 weeks)
- MLT on career ladder to BSCLS (LEAP online program)
- Categorical Certification Program (Microbiology, Hematology, Chemistry, Immunohematology)
- LEAP Career Ladder Program
- 2 + 2 BSCLS Program
In order to be eligible to apply for the Clinical Laboratory Initiative to Mentor Baccalaureate Students, potential participants must:
- Be a U.S. citizen (either U.S. born or naturalized), U.S. National, or Lawful Permanent Resident.
- Be eligible for in-state tuition.
- Be eligible for future enrollment or accepted as a full or part-time student in the UTMB CLS program.
- Have completed or in the process of completing all science prerequisites and receive an acceptance letter to the UTMB Clinical Laboratory Science (CLS) program
In order to qualify for admission to the CLIMBS Program applicants must complete and submit an application packet that includes the items listed belowbefore the CLIMBS semestersubmission deadlines: Fall (July 25), Spring (Nov 25), Summer (April 25).
Proof of U.S. citizenship (either U.S. born or naturalized), U.S. National or Lawful Permanent Resident
(Birth certificate, Passport, Permanent Resident card)
Eligible for in-state tuition. (Texas driver’s license or state issued identification)
Participant Application
Unofficial copy of your college transcript(s) If a foreign transcriptmust provide a WES Evaluation and TOEFL score.
A copy of your most recent tax return
Request a Wage Data report in writing to: Open Records Department, 101 East 15th St., Austin, TX 78778-0001,
(512) 463-2422; . A fee will be assessed for this report.
Acopy of your most recent Student Aid Report (obtain from
Proof that you are not in default on a Federal student loan. (go to this website
A copy of your resume with exact dates on employment
A copy of your DD-214 or an official notice of veteran status or spousal rights. (Required for Military
Veterans and spouses only)
Documentation of all unemployment benefits, federal benefits and/or government assistance, if applicable
CLIMBS Program
While enrolled in academics, participants receive:
- Payment of in-state tuition, fees and course required books/equipment. All payments will be made to approved vendors only. No payments or reimbursements can be made to individual students, without prior approval.
- In extenuating circumstances other fees may be approved.
Service Obligation
A commitment to seeking future employment in the CLS field with one of the CLIMBS Employer Partners or another healthcare employer.
Participant Responsibilities
- Maintain satisfactory academic performance. (GPA ≥ 2.0 with no grades lower than a C)
- Meet with the CLIMBS Academic Advisor a minimum of one time per semester or as necessary to discuss any issues that may affect school performance. Contacts may be via e-mail, telephone or personal visits.Failure to maintain contact with your advisor may result in being exited from the Clinical Laboratory Initiative to Mentor Baccalaureate Students.
- Immediately provide any changes in address or telephone number
- Attend classes, labs, meeting and workshops as scheduled
- Take advantage of the services provided through CLIMBS (guidance counseling, study skills, test taking, stress management, etc.) before a situation becomes a crisis
Participants who, due to personal or family illness, experience a delay in their education or temporarily move from the area must request a gap in service from the CLIMBS up to a period of 180 days.
Applications
Should an applicant not be approved for a grant award, their application packet and supporting documentation will remain active for the following academic semester and may require some updated documents. Following two semesters a potential participant will be required to resubmit all materials and follow the process as a new applicant.
Participant Exit
Participants who have completed their educational track, received certification and secured unsubsidized employment for 6 months will be considered completed and will be exited from the CLIMBS program. In addition, participants may be exited from the program prior to completion due to any of the following reasons:
- Withdrawal from partial or all registered semester classes;
- Failure to meet academic standards set by the UTMB CLS Program.
Please Note:
The following documents are required to be completed in its entirety upon submission or your application may be rejected
- Participant Application
- Authorization to Release Form
- Self-Attestation Form
Clinical Laboratory Initiative to Mentor Baccalaureate Students
Funded by U.S. Department of Labor Grant
Participant Application
Deadlines: Fall Semester: July 25 Spring Semester: November 25 Summer Semester: April 15
What Categorical Certificate Track are you interested in?
Chem Heme Immunohematology (Blood Bank) Micro 2+2 Current Student
Application Date: SSN: Gender: malefemale
Date of Birth: Email:
Last Name: First Name: Middle Initial:
Address:
Street City State Zip
Home Telephone: Work Telephone: Cell:
Emergency Contact Name: Emergency Contact Telephone:
Racial or Ethnic Group (Check all that apply):
White/Caucasian / Asian / Native Hawaiian/Pacific Islander / Other
Black/African American / Hispanic/Latino / American Indian/Alaska Native
Education: Please indicate your highest level of education, major, and date earned:
Some College Associates Degree
Bachelors Degree Masters Degree Other
Employment Status: Full time: Part time: Unemployed: Temporary/Contract:
Employer name:Title:
Supervisor name: Phone:
Employer Address:
StreetCityState Zip
Length of time with employer:Years Months Current Yearly Salary: $
If unemployed:(Attach TWC unemployment claim, or notice of termination or layoff)
- Were you terminated or laid off from work, self-employed and now unemployed? Yes No
- Are you receiving unemployment benefits? If yes, amount? $ per week. Yes No
- Are you currently looking for employment? Yes No
- Are you a Citizen, National or Lawful Permanent Resident of the United States
- Are you a Texas Resident or eligible for Texas (in-state) tuition? Yes No
- Are you a Veteran of the United States Armed Forces? Yes No
- Are you a spouse/widow of a Veteran of the United States Armed Forces? Yes No
of Veterans Affairs, or b) missing in action, captured in the line of duty
by a hostile force, or forcibly detained or interned in the line of duty by
a foreign government or power?
b)If you are the widow of a veteran, did the veteran:a) die of a service Yes No
connected disability; orb) die while a disability as evaluated by the
Department of VeteransAffairs was in existence?
Do you, your spouse or anyone in your household receive support from any federal Yes No
benefits programs or governmental assistance programs? If yes, indicate program(s)
and provide documentation.
Medicare/Medicaid / WIC / TANF / Public Housing Assistance
Social Security/SSI/SSD / SNAP/Food Stamps / CHIPS / Other
Are you currently in default on any federal debt or service obligation? Yes No
Do you have a judgment lien against you or your property arising Yes No
from a debt owed to the United States?
Have you ever been convicted of a felony or Class A Misdemeanor, or have a
felony case pending? Yes No
If yes, please describe:
The information requested on the questions below is optional and is being collected for the purpose of reporting to the Department of Labor. The information will not be considered in evaluating your application.
- Do you have any physical or mental impairment that substantially limits
- Do you have a limited ability in speaking, reading, writing or understanding the
b) the dominant language in the family or household is a language other than English? Yes No
I certify that the information on this application is true and correct to the best of my knowledge and ability.
Signature: Date:
Mail or fax to: CLIMBS Academic Advisor
Clinical Laboratory Initiative to Mentor Baccalaureate Students
301 University Blvd, Galveston TX 77555-1140
Fax: 409.772-3067
Clinical Laboratory Initiative to Mentor Baccalaureate Students
Funded by U.S. Department of Labor Grant
Authorization to Release Information
I, , hereby authorize:
(Print Name - First, Middle Initial, Last)
1) The institution in which I am enrolled while applying for (and if accepted) the Clinical Laboratory Initiative to Mentor Baccalaureate Students (CLIMBS) to disclose information pertaining to my school enrollment to the Department of Labor and the University of Texas Medical Branch at Galveston (UTMB). Information pertaining to my school enrollment includes, but is not limited to, my transcripts, grades, academic standing, enrollment and degree status, curriculum and examination requirements for graduation, tuition and fees, and leave-of-absence, withdrawal, or dismissal from school.
2) The entity/entities where I am/or will be employed to disclose to the Department of Labor and UTMB, information pertaining to my employment and any attached applicable employer provisions. Such information includes, but is not limited to, hire/termination date, employment location(s), employment responsibilities, length of employment and beginning/ending salaries.
3) The Department of Labor and UTMB, and/or its business and academic partners, to release my name, the academic institution I am attending, and my graduation date to health professions associations and to groups which have the responsibility for coordinating funds paid to students from Federal and other sources.
This authorization takes effect on the date I sign this release form and shall remain in effectuntil Nov.15, 2016. This authorization may be rescinded by me in writing at any time.
(Signature of Student) Date)
Mail or fax to: CLIMBS Academic Advisor
Clinical Laboratory Initiative to Mentor Baccalaureate Students
301 University Blvd, Galveston TX 77555-1140
Fax: 409.772-3067
Coordinated by:
Clinical Laboratory Initiative to Mentor Baccalaureate Students
Funded by U.S. Department of Labor Grant
Self-Attestation Form
Self-attestation forms are designed to allow individuals to authenticate information by signing documents indicating that information is true and accurate. Self attestation is permitted when efforts have been exhausted and it has been determined that the documentation is unavailable and/or obtaining the documentation would cause undue hardship for the individual.
Instructions: this self-attestation form is to be completed, signed and dated by the applicant to the Clinical Laboratory Initiative to Mentor Baccalaureate Students program.
Last Name: First Name: Middle Initial:
Social Security Number: Date of Birth:
Please check all statements below that apply to you:
I was laid off or terminated and have documented proof of the lay-off or termination
Name of employer: Date of termination/lay-off(exact date:mm-dd-yyyy):
I was laid off or terminated from my last job and unable to provide documented proof of the lay-off or termination.
Name of employer: Date of termination/layoff(exact date:mm-dd-yyyy):
I am employed but considered underemployed.
Name of employer: Current Position
Dates of current position (exact date:mm-dd-yyyy):to .
I was self-employed and am now unemployed.
Name of employer: Date of unemployment(exact date:mm-dd-yyyy):.
I am without a job and currently looking for employment.
Last date of employment(exact date:mm-dd-yyyy):.
I certify that the information provided above is true and accurate to the best of my knowledge and I understand that if I have provided misrepresented information I may be removed or deemed inelibilbe to receive grant funded services.
Name (printed): Signature: ______
Date:
Coordinated by
Mail or fax to: CLIMBS Academic Advisor
Clinical Laboratory Initiative to Mentor Baccalaureate Students
301 University Blvd, Galveston TX 77555-1140
Fax: 409.772-3067
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