TRIO Upward Bound College Prep Program Participant Application

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1 TRIO Upward Bound College Prep Program Participant Application Upward Bound is a program that helps students develop the skills and motivation necessary to graduate from high school and succeed in college. All Upward Bound program activities and services are free to students enrolled in the program. TRIO Upward Bound Pueblo Community College 900 West Orman Avenue Pueblo, CO Fax

2 Pueblo Community College TRIO Upward Bound Program APPLICATION CONFIDENTIALITY OF INFORMATION AND PRIVACY ACT The financial and educational information you provide to the Upward Bound Program is reported to the U.S. Department of Education and is protected by the Privacy Act. No one may see the information unless they are employed by the program or are specifically authorized by the US Department of Education to evaluate the project (20 USC 123 1a). STUDENT PERSONAL INFORMATION (Please print clearly.) Student Name: First: _ Middle: Last: Birth Date: // Social Security Number: - - Gender: Female Male Address: City: State/Zip Code: Address: Student Cell #: () Citizenship: US Citizen Other Ethnicity: Hispanic/Latino American Indian/Alaska Native African American Asian Permanent Resident (Attach copy of residency card) White/Caucasian Native Hawaiian/Pacific Islander Other HIGH SCHOOL COUNSELOR OR TEACHER RECOMMENDATION APPLICATION MUST INCLUDE COPIES OF THE APPLICANT S: TRANSCRIPT TCAP ICAP IEP Applicant s Name: Grade Level: GPA: School SASID #: Counselor s Name: Signature: Phone: Are there any circumstances/disabilities that might affect the student s academic progress. Circle: Yes No Please rate the student according to the criteria listed below. (1 Low through 5 High) Response Items Oral Communication Written Communication Math Reasoning Study Skills Leadership/Motivation Integrity/Good Behavior I highly recommend this applicant I do not recommend this applicant SCHOOL RECORDS RELEASE FORM HIGH SCHOOL & COLLEGE filled out by Parent/Guardian This form will be used by the Pueblo Community College to access necessary academic records for current and/or prior participants of the TRiO Upward Bound College Prep Program, during high school and four years after graduation, as directed by the United States Department of Education, for reporting purposes only. Authorization to release records of _ I,, (SS# ), as an active or prior participant of the TRiO Upward Bound Program, do hereby permit the release of my academic records in high school and in college, including, but not limited to grades, transcripts, individual education and career action plans (ICAPS), standardized test scores (TCAP, ACT, Terra Nova, Accuplacer, etc), and proof of high school and/ or college graduation to the TRiO Upward Bound Program at Pueblo Community College for the purpose of compiling and reporting data to the United States Department of Education, Office of Post-Secondary Education annually. I understand that the United States Department of Education requires the TRiO Upward Bound College Program at Pueblo Community College to report on my academic progress through my high school years, graduation from college, and/or for at least four years after my expected high school graduation. My expected high school graduation cohort date is/was. I understand that Upward Bound staff will request this information for at least four years after this date. Student Signature: Date: _ Parent/Guardian Signature: Date: TRIO Upward Bound Pueblo Community College 900 West Orman Avenue Pueblo, CO Fax

3 Pueblo Community College TRIO Upward Bound Program PARENT OR LEGAL GUARDIAN INFORMATION Mother s Name: Occupation: _ Mother s Cell #: (_)_ Home Phone: (_)_ Father s Name: Occupation: _ Father s Cell #: (_) Home Phone: (_) Legal Guardian s Name: Occupation: _ Legal Guardian s Cell Phone: (_) Home Phone: (_)_ Educational Level of Mother (Please check the box): No College 2-Year Degree 4-Year Degree Educational Level of Father (Please check the box): No College 2-Year Degree 4-Year Degree Educational Level of Legal Guardian (Please check the box): No College 2-Year Degree 4-Year Degree Parent/Legal Guardian s Signature: Date: PARENT/LEGAL GUARDIAN & STUDENT MEDICAL INFORMATION Throughout the year, students will participate in a variety of field trips with the Upward Bound Program. It is necessary that we have an accurate medical history in the event that emergency treatment is required. All information is confidential. Any student without a signed and completed Medical Information Form will not be allowed to participate in such field trips. Student Name Parent/Guardian Name Home Phone Work Phone Emergency Contact and Phone Number Medical Insurance Information: Policy Holder s Name Policy number Insurance Company Group number _ Insurance Company Address Insurance Company Phone Number Physician s Name _ Phone number Medical History of Student (Check ALL items that apply): Diabetes Drug Allergy Food Allergy Insect Bite Allergy Heart Defects Convulsions/Epilepsy Asthma Physical Restrictions Currently taking medications Currently under doctor s care Date of last Tetanus shot: List of current medications or current medical conditions: Parent/Guardian Signature: _ Date: TRIO Upward Bound Pueblo Community College 900 West Orman Avenue Pueblo, CO Fax

4 Pueblo Community College TRIO Upward Bound Program FAMILY FINANCIAL INFORMATION Financial Information: Custodial Parent s financial information must be completed in its entirety for consideration under federal income guidelines and for staff to establish eligibility. Please call the Upward Bound Office prior to submitting the application if you have any questions The U.S. Department of Education provides more information about TRiO and eligibility requirements on its web site: (Effective January 28, 2014 until further notice.) Name of Student: Proof of income is required by the federal government to determine if your child is eligible to be a part of Upward Bound. Please choose a category to complete: III. YES, I FILE WITH THE IRS IV. NO, I DO NOT NEED TO FILE A TAX RETURN Please complete statement My taxable income from my 2014 Federal Tax Return was $ _ (See 1040 line 43, 1040A line 27 or 1040EZ line 6.) Please submit a copy of your signed Federal Tax Return. My total family income for 2014 (before taxes) is: $. By filling out this amount, parent is requesting that the amount be converted to taxable income using standard IRS deductions and exemptions. Type of assistance received (check all that apply): Social Security Benefits Child Support Number of people in household. Include yourself, your spouse, your children and any other individual who is receiving more than half of their support from you. Number of parents living in household. Include legal parent or guardian only. Rent Subsidies Food Stamps Other: Please submit copies of your signed income/benefits Marital Status: Single Married Separated Number of people in household. Include yourself, your spouse, your children and any other individual who is receiving more than half of their support from you. Number of dependent children living in household. V. AFFIDAVIT: I certify that the above information is true and correct and all income is reported. I understand that any information found to be incorrect and/or any misrepresentation or false statement will render the applicant ineligible for the Pueblo Community College upward bound program. Mother s Signature: Date: Father s Signature: Date: Legal Guardian s Signature: Date: TRIO Upward Bound Pueblo Community College 900 West Orman Avenue Pueblo, CO Fax

5 Dear Parent (s) and Student, Thank you for your interest in the Upward Bound College Prep Program at Pueblo Community College. Upward Bound is a federally funded program designed to prepare eligible high school students for a successful two or four years of college. Program services include, but are not limited to: College Readiness Lab/tutoring, academic instruction, cultural enrichment, career exploration, financial aid application assistance, college visits, and support services designed to assist students as they prepare for entry into and ultimately graduation from a two or four year college. We hope that we will have the opportunity to assist you as you pursue your educational goals. Each item listed below is necessary for consideration for the Upward Bound Program. Once you have completed the enclosed information, please return it to Pueblo Community College Upward Bound Program, 900 W. Orman Avenue in the Academic Building, Room 154, Pueblo, Colorado, To speed up the process of reviewing this application, we ask that you return the COMPLETED AND SIGNED information as soon as possible. The application must have the following completed pieces: Completed Student Application Form with ALL Signatures Completed Student Application with student and parent signatures (must have Social Security Number filled out) Completed Student Application Academic Need/Essay Form Initialed and Signed Student Contract Form Release forms for Field Trips, , Photographs and Medical Release Form PCC Release from Responsibility, Assumption of Risk, and Waiver Form (Student Signatures) Signed W-9 Form with Social Security Number Completed Parent/Guardian Application with ALL Signatures Completed Custodial Parent/Guardian Information Form Completed Family Financial Information o Please include a signed copy of current Federal 1040 (line 43) OR a letter confirming that you are on a fixed income. Completed Parent Contract Form PCC Release from Responsibility, Assumption of Risk, and Waiver Form Completed Medical Information Form Completed School Records Release portion of Student Application with Student and Parent Signatures Completed High School Counselor Recommendation Forms with ALL Signatures Completed High School Counselor Recommendation Portion of Student Application Current Academic Transcripts/ Current Grade Check Standardized Test Scores or ACT or Accuplacer scores If the application is not complete, or is missing income information, transcripts, etc., it CANNOT be processed. Information not relative to your status must be filled in with N/A. Please call us with any questions or for help in completing this application at % federally funded serving 76 students.

6 Why Do You Want to Join TRIO Upward Bound (to include self- identified academic need)? (Please select ALL that apply) Academic Advisement Community Service Activities Social, Cultural, and Educational Events Skill Building Workshops in areas of Study and Test-Taking Skills, Time Management and Career Exploration Accuplacer/ACT Prep Tutoring Financial Aid Advisement Career Counseling Personal Counseling College Campus Tours Were you referred to TRIO Upward Bound? Yes No If Yes, by whom? PCC Upward Bound student or Staff MYLIFE Program School Counselor, Teacher or other School Figure Other Receiving Assistance with Achieving or Maintaining a 2.5 GPA while in High School College Preparation (college applications, scholarships, financial aid, resume/cover letter, personal essay, etc.) Academic Support and Motivation (weekly, monthly, semester, and yearly) Academic and Career Goal Setting In your own words, tell us why you want to participate in the TRIO Upward Bound program and how the TRIO Upward Bound program will help you become successful. _

7 Pueblo Community College-Upward Bound College Prep Program STUDENT CONTRACT In order to participate in the Upward Bound College Prep Program, I agree to the following statements: (Please initial all points) I understand that Upward Bound is a college preparatory program and that by participating, I am agreeing to apply for, attend and graduate from college (two or four year). I understand that the Upward Bound Program is an academic program that assists me in my academic pursuits while in high school and will track my success during my college career. I understand that while in high school, I will work with the UB advisor to develop, implement, and update my Individual Career & Academic Plan to meet my post-secondary education goals (This will be done using an Upward Bound Passport). I understand that when I first am accepted into the Upward Bound Program, I will immediately take the Accuplacer and be placed on a 90-day probation period to ensure that I am actively participating and engaged. I understand I am required to maintain a cumulative GPA of 2.5 or higher or I will be placed on Performance Alert with the Upward Bound program. I understand that I am required to attend hours in College Readiness Lab/tutoring sessions each month which takes place at PCC, Central high school, and CSU-P. I understand that I am to participate in four service learning activities hosted by the Upward Bound program each year. I understand that I am to participate in scheduled Monday night workshops, field trips and cultural activities. **(Prior approval of absence from any activity must be granted by the Upward Bound staff in order to make-up activities) I agree to keep my UB Counselor informed of any extra-curricular activities that I am involved in and will work with the UB staff to ensure that I remain in good academic standing and maintain the requirements of the Upward Bound Program. I understand that I am required to notify the UB office if an appointment needs to be rescheduled. I understand that I am required to attend an academic advising session once a month during the Academic year and a student/parent conference once a semester. I understand that I will attend the six-week Upward Bound summer session. I understand that students & parents are required to volunteer/participate in the two major TRIO UB fundraisers: Bowl-a-thon/silent auction & The Mexican dinner/silent auction every year. I agree to behave in a mature and responsible way with my parents, teachers, tutors, administrators, Upward Bound staff and peers, by following all community, school and Upward Bound rules as well as show respect for myself. I understand that if I do not perform according to the program s requirements or I break this contract, I may not receive my stipend, and /or I may be dropped from the program. I, (Print Student Name) understand that I am agreeing to participate fully in all academic and social components of the Upward Bound College Prep Program at Pueblo Community College. I further agree to comply with all rules and regulations established by the Director and Staff of the Upward Bound Program. (Sign Student Name)

8 Pueblo Community College, Upward Bound College Prep Program PARENTAL PERMISSION AND SUPPORT Student Name: Parental Permission: has my permission to be a participant in the Upward Bound College Prep Program at Pueblo Community College. It is understood that I agree to his/her participation in all activities, whether academic, civic or recreational, both on and off the PCC Campus. In the case of an emergency during an official Upward Bound activity, I authorize my son/daughter to be treated by qualified Southern Colorado Medical personnel at St. Mary Corwin or Parkview Hospital in Pueblo, Colorado or other qualified medical personnel while outside of Pueblo. Parent/Guardian Signature _ Date Parent/Guardian Support Agreement: In order for my student to participate in the Upward Bound College Prep Program, I agree to the following statements: (Please initial all points) I understand that Upward Bound is a college preparatory program and that by applying to Upward Bound, my student is agreeing to participate throughout their high school years, both during the academic year and six weeks in the summer. I understand that after high school graduation, my student will enroll in a two or four-year college. I understand that the Upward Bound program is an academic program that assists and tracks student s progress in academic pursuits while in high school and throughout college. I understand that I am required to attend both Summer and Fall UB Orientations with my student. I understand that I am required to attend a parent/student academic conference once a semester. I commit to supporting my student by encouraging them to fulfill all requirements of the Upward Bound program. This includes my student maintaining a 2.5GPA per semester, attending the College Readiness Lab/tutoring, weekly workshops, service learning projects, and other cultural activities. I commit to attending the Upward Bound family workshops and assisting and participating with the two major fundraising activities: Bowl-a-thon/Auction and Mexican Dinner/Auction. I commit to attending monthly Parent Advisory Committee meetings. I understand that I am responsible for informing UB staff of any changes regarding addresses, s, and cell/home phone numbers. I commit to supporting my student s dream of a college education. Parent/Guardian Signature _ Date

9 Field Trip Release: Pueblo Community College, Upward Bound College Prep Program RELEASES Student and Parent must initial each section and sign at the bottom of the page. I hereby affirm that I am a participant in the Upward Bound Program. I hereby waive and release all claims against the State Board for Community Colleges and Occupational Education (SBCCOE), Pueblo Community College (PCC), as well as their agents and employees for any injury, damage, delay or expense incurred by me during the course of any field trips or activities during the Program Year. Also, I release PCC and their agents and employees from any liability for any damage or injury to the person or property of others that I may cause while on any or all field trips or activities with the Pueblo Community College Upward Bound Program. Student Initial Parent Initial address and Photograph Release: Upward Bound often uses photographs and video of participating students for recruiting activities and are often included on the PCC Upward Bound website and social network sites. We do not identify the students by name and we have never had any complaints or problems from this activity. We feel that students and their parents need the right to accept or refuse having their image put forth in the public domain. Upward Bound would also like to communicate with students and parents via . In order to accomplish this task, each student and parent needs to provide a valid address and keep us informed of any changes. Computer access is available through our program, if one is needed to create an address. By initialing this form, you are releasing your address to the Upward Bound staff only. The addresses will not be shared with any other entity. Student Initial Parent Initial Student address _ Parent address Medical Release: In the event that I, the parent, cannot be contacted and there is a medical emergency involving my Upward Bound student, I hereby authorize the staff of the Pueblo Community College to take appropriate action in securing professional medical attention. Student Initial Parent Initial By signing this form below, I verify that I have read and understood all releases on this page. If I have any questions Student Printed Name Student Signature Parent Signature

10 READ THIS DOCUMENT COMPLETELY BEFORE SIGNING. ITS EFFECT IS TO RELEASE PUEBLO COMMUNITY COLLEGE, THE STATE BOARD FOR COMMUNITY COLLEGES AND OCCUPATIONAL EDUCATION, AND THE STATE OF COLORADO FROM ANYLIABILITY RESULTING FROM YOUR PARTICIPATION IN THE ACTIVITIES DESCRIBED BELOW, AND TO WAIVE ALL CLAIMS FOR DAMAGES OR LOSSES AGAINST THE STATE, THE BOARD OR THE COLLEGE WHICH MAY ARISE FROM SUCH ACTIVITIES. RELEASE FROM RESPONSIBILITY, ASSUMPTION OF RISK, AND WAIVER PARTICIPANT S FULL NAME: _ DATE OF BIRTH (MO/DAY/YR): ADDRESS: TO BE COMPLETED BY STAFF LOCATION OF ACTIVITY(IES): DATE(S) OF ACTIVITY(IES): START DATE: END DATE: Check one: STUDENT OR NON-STUDENT INSURANCE INFORMATION: IF STUDENT: I am aware that as a student of Pueblo Community College, I can purchase travel and accident insurance through an insurance carrier or agent, and that I am required to purchase such insurance to participate in the above-named activities. NAME OF INSURANCE CARRIER: POLICY NUMBER: I, the undersigned participant, exercising my own free choice to participate voluntarily in the above-named activities, and promising to take due care during such participation, hereby release and discharge, indemnify and hold harmless the State Board for Community Colleges and Occupational Education and Pueblo Community College, and their members, officers, agents, employees, and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and entities, against any and all claims, demands, and causes of action whatsoever, whether presently known or unknown, either in law or in equity, relating to injury, disability, death or other harm, to person or property or both, arising from my participation in and/or presence at the above listed activities. I acknowledge that I have been informed of the nature of the activities and that I am aware of the hazards and risks which may be associated with my participation in the above-named activities, including the risks of bodily injury, death or damage to property which may occur from known or unknown causes. I understand, accept, and assume all such hazards and risks, and waive all claims against the State of Colorado, the State Board for Community Colleges and Occupational Education, and Pueblo Community College, and other persons as set forth above. I understand that I am solely responsible for any costs arising out of any bodily injury or property damage sustained through my participation in normal or unusual acts associated with the above-named activities. I have had sufficient time to review and seek explanation of the provisions contained above, have carefully read them, understand them fully, and agree to be bound by them. After careful deliberation, I voluntarily give my consent and agree to this Release from Responsibility, Assumption of Risk, and Waiver. Signature of Participant whose printed name appears above: Signature of Participant Witness over 18 years of age (Participant must sign in the presence of the Witness) If participant is under 18 years of age, his or her parent or legal guardian must also sign: I, (printed name), am the parent or legal guardian of the participant who has signed above. I have read and I understand the provisions of this document, I consent to the participant taking part in the program activities during the school year and I fully enter into and agree to the above Release from Responsibility, Assumption of Risk, and Waiver. Signature of Parent or Legal Guardian Witness over 18 years of age (Parent or Guardian must sign in the presence of the Witness)

11 Pueblo Community College, Upward Bound College Prep Program MEDICAL INFORMATION FORM Throughout the year, students will participate in a variety of field trips with the Upward Bound Program. It is necessary that we have an accurate medical history in the event that emergency treatment is required. All information is confidential. Any student without a signed and completed Medical Information Form will not be allowed to participate in such field trips. Student Name Birth date Social Security Number _ Address Parent/Guardian Name Home Phone _ Work Phone _ Emergency Contact and Phone Number Medical Insurance Information Policy Holder s Name Policy number _ Insurance Company Group number _ Insurance Company Address Insurance Company Phone Number _ Physician s Name Phone number _ Medical History of Student Check ALL items that apply to the student Diabetes Drug Allergy Food Allergy Insect Bite Allergy Heart Defects Convulsions/Epilepsy Asthma Physical Restrictions Currently taking medications Currently under doctor s care Date of last Tetanus shot Please list all current medications and any other medical conditions that may require treatment: _ Parent/Guardian Signature Date

12 Embedded Adobe XML Form The file is an Adobe XML Form document that has been embedded in this document. Double click the pushpin to view. 10:23:31 AM]

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