Clinical Laboratory Initiative to Mentor Baccalaureate Students
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)
The course of study will follow the career plan outlined below, but is not limited to succession of the steps, with a large
focus being on Long Term Unemployed.
 Categorical Certification Program (Microbiology, Hematology, Chemistry, Immunohematology)
 LEAP Career Ladder Program
 2 + 2 BSCLS Program
Eligibility Requirements
In order to be eligible to apply for the Clinical Laboratory Initiative to Mentor Baccalaureate Students, potential participants
must:
a. Be a U.S. citizen (either U.S. born or naturalized), U.S. National, or Lawful Permanent Resident.
b. Be eligible for in-state tuition.
c. Be eligible for future enrollment or accepted as a full or part-time student in the UTMB CLS program.
d. Have completed or in the process of completing all science prerequisites and receive an acceptance letter to the
UTMB Clinical Laboratory Science (CLS) program
Required Documentation
In order to qualify for admission to the CLIMBS Program applicants must complete and submit an application packet that
includes the items listed below before the CLIMBS semester submission 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 transcript must 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; Open.records@twc.state.tx.us . A fee will be assessed for this report.
A copy of your most recent Student Aid Report (obtain from http://www.fafsa.ed.gov/)
Proof that you are not in default on a Federal student loan. (go to this website http://www.nslds.ed.gov)
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
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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.
Please Note: All non-tuition related expenses must have supporting documentation and authorization through the
CLIMBS program prior to purchase.
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
Gap in CLIMBS Service
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.
While on “Exited” status, participants are not supported with tuition, fees, book, or misc. expenses. Exited participants who
wish to be reconsidered for CLIMBS funding must apply for readmission and resubmit all forms. All exited participants will
be required to complete a Student Exit Survey.
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Please Note:
The following documents are required to be completed in its entirety
upon submission or your application may be rejected
A. Participant Application
B. Authorization to Release Form
C. Self-Attestation Form
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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)
Application Date:
Date of Birth:
Last Name:
SSN:
Micro
2+2
Current Student
Gender:
Email:
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
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Other
Education: Please indicate your highest level of education, major, and date earned:
Some College
Associates Degree
Bachelors Degree
Masters Degree
Employment Status: Full time:
Employer name:
Part time:
Other
Unemployed:
Temporary/Contract:
Title:
Supervisor name:
Phone:
Employer Address:
Street
Length of time with employer:
City
Years
State
Months
Zip
Current Yearly Salary: $
If unemployed: (Attach TWC unemployment claim, or notice of termination or layoff)
1. Were you terminated or laid off from work, self-employed and now unemployed?
If so, date of termination (exact date:mm-dd-yyyy):
2. Are you receiving unemployment benefits? If yes, amount? $
per week.
3. Are you currently looking for employment?
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Yes
No
Yes
Yes
No
No
4. Are you a Citizen, National or Lawful Permanent Resident of the United States
and eligible to work in the United States?
5. Are you a Texas Resident or eligible for Texas (in-state) tuition?
6. Are you a Veteran of the United States Armed Forces?
7. Are you a spouse/widow of a Veteran of the United States Armed Forces?
a) If you are the spouse of a veteran, is the veteran: a) totally disabled as a
result of a service connected disability, as evaluated by the Department
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?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
b) If you are the widow of a veteran, did the veteran: a) die of a service
connected disability; or b) die while a disability as evaluated by the
Department of Veterans Affairs was in existence?
Yes
No
Do you, your spouse or anyone in your household receive support from any federal
benefits programs or governmental assistance programs? If yes, indicate program(s)
and provide documentation.
Yes
No
Medicare/Medicaid
Social Security/SSI/SSD
WIC
SNAP/Food Stamps
TANF
CHIPS
Public Housing Assistance
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
from a debt owed to the United States?
Yes
No
Yes
No
Have you ever been convicted of a felony or Class A Misdemeanor, or have a
felony case pending?
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.
1. Do you have any physical or mental impairment that substantially limits
one or more major life activities, or being regarded as having an impairment?
Yes
No
2. Do you have a limited ability in speaking, reading, writing or understanding the
English language and a) the native language is a language other than English, or
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:
Coordinated
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
by:
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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 effect until 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:
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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:
Social Security Number:
Middle Initial:
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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