Upward Bound is a federally funded program, which provides eligible students with academic support services and activities that will enhance their academic skills, thereby ensuring that these students will complete high school and enroll in and complete programs of post-secondary education.  The program provides an array of academic, educational, and career support.

Student Information Section:
Name of High School *
Current Grade Enrolled *
Social Security Number *
First Name *
Middle Name
Last Name *
Street Address *
Mailing Address
City *
State *
Zip Code *
Cell Phone Number
Home Phone Number
Student Email Address *
Gender *
Date of Birth *
Place of Birth *
U. S. Citizenship *
Ethnicity *
Do you have a documented physical or learning disability? *
A Member of Educational Talent Search *
Do you have a court appointed guardian *
Do you live with foster parents? *
Do you plan to attend college immediately after high school graduation? *
What are your college and career plans? *
Do you participate in any extracurricular activities and employment? If yes, please list. *

Parent/Guardian Information Section:
Name *
Street Address *
Parent/ Guardian Mailing Address
Contact 1 Cell Phone *
City *
State *
Zip Code *
Home Phone
Work Phone
Email Address *
Marital Status *
Does either parent or guardian received a Bachelor's Degree (4-year College)? *
Household size *
What is your family's Taxable Income for last year? Choose 0 if didn't file *
Upload copy of Most Recent Federal Tax Form
Upload copy of High School Transcript

RELEASE & LIABILTY FORM
The information requested on this form will be utilized to assist us in providing services for your child. To provide the most effective services, we may need to obtain information from several sources such as guidance counselors, colleges, testing agencies, admissions and financial aid offices, social workers, etc. ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT.
 SCHOOL RECORDS
As the parent and/or legal guardian of the applicant, I grant Upward Bound permission to obtain school records, transcripts, grade reports, test results, and financial aid transcripts from the secondary school and/or college my child is attending. I will also permit Upward Bound staff to speak with teachers, counselors, and other school administrators at my child’s school in order to obtain and exchange information as part of the services my child will receive from the Upward Bound Program. I authorize the Upward Bound Program to access or release copies of my child’s academic transcripts, test scores, college admissions enrollment, and financial aid information that are necessary to assist my son/daughter in achieving his/her educational goals.

WAIVER OF LIABILITY
(Students WILL NOT be allowed to attend trips if section is incomplete!)
As a parent and/or legal guardian of the above-mentioned student, I authorize and permit my child to participate in field trips, activities, and events offered by the Upward Bound Program. I understand that my child may be leaving his/her school campus or James Sprunt Community College and may be transported by the Upward Bound staff of James Sprunt Community College. I agree that James Sprunt Community College, Upward Bound, and anyone associated with James Sprunt Community College will not be held liable for any loss, injury, or death related to any field trips, or events. Further, I agree to hold James Sprunt Community College, Board of Trustees, President’s Council, Upward Bound, officers, staff, and volunteers harmless from any claims whatsoever occasioned in any of the situations that I have agreed.

In the event that my child is involved in a medical emergency, I authorize the Upward Bound staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc.) if they are unable to contact me for verbal authorization.

MEDIA RELEASE
Periodically, students participating in Upward Bound events may be photographed, filmed, or interviewed. As the parent and/or legal guardian of the applicant, I grant permission for my child to participate in photographs, films, or interviews as they pertain to the Upward Bound Program and I understand that such pictures, film, or interviews may be used to promote or publicize Upward Bound events or demonstrate how federal funds are being used to assist students.

STUDENT CONTRACT
As a member of the James Sprunt Community College Upward Bound Program, I accept the following responsibilities and agree to:

· attend all Upward Bound classes, workshops and scheduled tutoring sessions.

· conduct myself appropriately at all times.

· uphold the policies of the Upward Bound Program.

· strive for academic excellence by satisfactorily completing my UB classes/tutoring.

· strive to develop leadership qualities.

· adhere to the Upward Bound disciplinary policy.

As a member of the James Sprunt Community College Upward Bound Program, I accept responsibility for the fulfillment of the above obligations. I understand that failure to attend and/or participate in Upward Bound activities, maintain the minimum GPA, or to fulfill the requirements of this contract could result in my dismissal from the program.

I promise to be in attendance, abide by the rules and regulations, and participate fully in all activities. I further understand that the following behaviors may result in automatic dismissal from the Upward Bound Program. I WILL NOT engage in any of the following:

· Possession of alcohol, tobacco, vaping items or illegal drugs

· Sexual misconduct

  • ×Bullying

· Physical or verbal abuse of staff/tutors or another student

· Possession of weapons or fireworks

· Stealing or shoplifting

· Intentional damage of property

As the parent or legal guardian of the applicant, I agree to support the rules and decisions of the Upward Bound Program.

My electronic signature certifies that the above information is true and accurate.  I understand that this information is confidential and will only be used to determine eligibility for the Upward Bound Program as set forth by the United States Department of Education.

Sign and Submit:
Student Signature *
Signature Type: Simple    Start Over
Signature: (Type in your full name)
I agree to the terms included.
Parent/Guardian Signature *
Signature Type: Simple    Start Over
Signature: (Type in your full name)
I agree to the terms included.

This Section Completed by Upward Bound Staff Only:

Eligibility: ___LI Only ___FG Only ___LI & FG ___LI & HR ___FG & HR ___LI, FG & HR ___HR Only

Academic Need:__________________________________________________________________________________________

____Accepted ____Denied Date of Acceptance:____/____/______