Middle School Application

Company

This field is for validation purposes and should be left unchanged.

Student Information

For this section, please answer the following demographic information regarding the student applying to be a part of UP RVA.

Student Name*

First Middle Initial Last

Student Preferred Name

Student Date of Birth*

Student Permanent Address*

Street Address Address Line 2 City State ZIP Code

Student Mailing Address

Student's mailing address is different than their permanent address.

Student Mailing Address*

Street Address Address Line 2 City State ZIP Code

Student Phone Number*

Student Gender*

Student Racial Identity*

Please describe the racial/ethnic identities this student most identifies with.*

Does the student have an IEP, 504, or other form of accommodations?*

If yes, please explain:*

Custodial Parent/Guardian #1's Information

For this section, please answer for the student's primary custodial parent/guardian. If you are the primary parent/guardian and filling out this form, this will be your information.

Custodial Parent/Guardian #1's relationship to the student is:*

Custodial Parent/Guardian #1 Name*

First Middle Initial Last

Custodial Parent/Guardian #1 Preferred Name

Custodial Parent/Guardian #1 Date of Birth*

Custodial Parent/Guardian #1 Permanent Address*

Street Address Address Line 2 City State ZIP Code

Custodial Parent/Guardian #1 Mailing Address

Custodial Parent/Guardian #1's mailing address is the different than their permanent address.

Custodial Parent/Guardian #1 Mailing Address*

Street Address Address Line 2 City State ZIP Code

Custodial Parent/Guardian #1 Email Address*

Enter Email Confirm Email

Custodial Parent/Guardian #1 Phone Number*

Please choose the option that best describes Custodial Parent/Guardian #1's legal custody of the student:*

Please briefly describe your custodial relationship with the student.*

Custodial Parent/Guardian #1 Racial Identity*

Please describe the racial/ethnic identities you most identify with.*

Custodial Parent/Guardian #1 Marital Status*

Custodial Parent/Guardian #1 Highest Education*

Please list the colleges/universities where these degrees were attained.*

Does the student have a second Custodial Parent/Guardian?

Parent/Guardian #2's Information

For this section, if the student has/had a second parent/guardian, please fill out this section. If you do not have the information and cannot attain this information, please mark N/A on those questions.

Parent/Guardian #2's relationship to the student is:*

Parent/Guardian #2 Name*

First Middle Initial Last

Parent/Guardian #2 Preferred Name

Parent/Guardian #2 Date of Birth*

Parent/Guardian #2 Permanent Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 Mailing Address

Custodial Parent/Guardian #2's mailing address is the different than their permanent address.

Parent/Guardian #2 Mailing Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 Phone Number*

Parent/Guardian #2 Email Address*

Please choose the option that best describe Parent/Guardian #2's legal custody of the student:*

Please briefly describe their custodial relationship with the student.*

Parent/Guardian #2 Racial Identity*

Please describe the racial/ethnic identities this person most identifies with.*

Parent/Guardian #2 Marital Status*

Parent/Guardian #2 Highest Education*

Please list the colleges/universities where these degrees were attained.*

Family Housing/Income Information

Please list the full name, age, and relationship to the student of anyone besides the student's guardian(s) that also live full-time in the household. If no one else lives in the household, type N/A.*

Does the student currently reside primarily in Richmond Public Housing and/or receive a Section 8 housing voucher?*

Which public housing community does the student reside in?*

What was the approximate total family household income last year (2024)?*

Parent/Guardian Records Request and Application Confirmation

Initials*

As part of the admissions evaluation process, UP RVA and its representatives may need to request information regarding your student from their current and previous schools. This could include transcripts as well as teacher evaluations and/or recommendations. Please give permission for UP RVA to request this information by typing your [Parent/Guardian] first and last initials and the date in the space below.

Date*

Signature*

By signing my [Parent/Guardian] name in the space above, I certify that all the information provided in this application is factually true and honestly represented. I understand that any false information submitted by the student and/or parent/guardian in the application process will put a student's consideration for participation in UP RVA at risk.

Date*

Student and family demographics

Student Information

Custodial Parent/Guardian #1's Information

Parent/Guardian #2's Information

Family Housing/Income Information

Parent/Guardian Records Request and Application Confirmation

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