DelawareTechnical & Community-Dover-UB-Application Form

DELAWARE TECHNICAL COMMUNITY COLLEGE
Classic Upward Bound Program
Student Name*

First NameM.I.Last Name
Mission Statement

Classic Upward Bound (CUB) empowers participants to complete high school and enter and complete a program of postsecondary education by providing academic support, personal guidance, parent education, and enrichment services in the areas of study skills, college preparation, and financial aid.

Classic Upward Bound is required by the U.S. Department of Education to obtain information requested in this application and ensures that all information provided will be held in confidence.

The Application Process
- Incomplete application packets will not be considered. Please answer all questions. Use N/A (Not Applicable) or 0 for numbers rather than leaving a question blank.
- Once your application is submitted CUB will contact your School Counselor and two teachers for recommendations.
- List two of your teachers (1-English, 1-Mathematics) and your school guidance counselor to provide information about you that would be helpful in your selection for participation in the CUB program.
Teacher 1 Name*

First NameLast Name
Teacher 1 Email*
example@example.com
Teacher 2 Name*

First NameLast Name
Teacher 2 Email*
example@example.com
Guidance Counselor Name*

First NameLast Name
Guidance Counselor Email*
example@example.com
- CUB will obtain the references from the teachers and counselor you listed above.
- CUB will conduct interviews with eligible students at the high school or through Zoom.
- CUB will conduct interviews with parent / guardian at the Delaware Tech Terry Campus or through Zoom.
- For more information contact the CUB office at 302-857-1400.

Student Questionnaire
Student Name*

First NameM.I.Last Name
Please answer the following questions. Your answers should be thoughtful and well organized. Please write neatly and proof read your work.
1. What would you like to do after you graduate from high school?*
2. What type of people do you think go to college?*
Are you this type of person?*
3. Who encourages you to go to college? What do they say and/or do to encourage you? *
4. What is the one thing you really like about yourself and why?*
5. Please list other school or community activities that you are currently involved in:*

6. Please list three careers that interest you*

	Career Name
1
2
3

Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian please initial here after reading*
Date*

MonthDayYear
mm-dd-yyyy

Parent Questionnaire
Student Name*

First NameM.I.Last Name
Please answer the following questions to help us assess your child’s needs and your expectations of the Upward Bound Program.
1. How will your child benefit from being a part of the Upward Bound Program? *
2. What can Upward Bound do to best support you and your child in the pursuit of their academic and career goals? *
3. Being a part of the Upward Bound program is a commitment that extends through your child’s graduation from college. Are you and your child able and willing to commit to meetings, workshops, summer enrichment, and any other necessary Upward Bound events and activities? Please describe your commitment level and willingness to support the Upward Bound mission. *
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian Signature*

Clear
Parent/Guardian Name (Printed)

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy

Needs Assessment
Student Name*

First NameM.I.Last Name
Which services would you benefit from to be more successful in high school and college? Please check all that apply.*

TutoringAcademic advisementProfessional mentoringAssistance with college admissionTest preparation (Smarter, SAT, ACT)Personal counselingAssistance using technologyActivities to build confidence, self-esteem &/or social skillsParent workshops/family activitiesLanguage assistance (LEP/ESL students)College & cultural visitsStudy skillsCareer awarenessResearch proceduresFinancial/Economic LiteracyCollege Financial Aid/ScholarshipOther
Why do you think you need the services of Classic Upward Bound? Please check all that apply.*

My Grade Point Average (GPA) is lowMy Smarter/DCAS score is below ‘3 ’in English, math, and/or writingI don’t think I’m college material but I may want to goI won’t have help if I take challenging coursesI’m not sure what career is best for me and/or I need more information about my career choiceEnglish is not my native language and I have difficulty speaking, reading, writing or understanding EnglishI need to improve my confidence, self-esteem and/or social skillsI live in a low-income community with few opportunitiesI live in a rural community with few opportunitiesI’m interested in careers in math and scienceI have a diagnosed learning disabilityOther

Service Provision: I understand that Classic Upward Bound is a year-round program and that full participation is expected. I am able and willing to participate in:*

	yes	no	unsure
Weekly meetings during the school day
After-school tutoring
1-2 Saturday workshops each month
6-week summer program at Delaware Tech

Student Signature*

Clear
Student Name (Printed)*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian please initial here after reading*
Date*

MonthDayYear
mm-dd-yyyy

Student Information Release Form
I hereby give permission for the college system to release information to the TRIO program (Classic Upward Bound). This exchange of information includes: course schedule, transcripts, counselor’s reports, degree attained, financial aid information, and any other information deemed necessary for the purpose of tracking my college enrollment, persistence, progression, and completion.
Student Signature*

Clear
Student Name (Printed)

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy

TRIO Follow-up Contacts
According to funding guidelines, Classic Upward Bound is required to follow-up on program alumni for six years after high school graduation. To assist in the process the program requests that you identify four individuals, such as grandparent, aunt/uncle, older sibling, or cousin, who are likely to know the whereabouts of the applicant in case parents/guardians identified in this application cannot be located due to change of address or phone number.
Student's Name*

First NameLast Name

Individuals' Information*

	Name	Relationship	Address	Phone
1
2
3
4

Academic Monitoring
Academic Monitoring

To enable Classic Upward Bound (CUB) to better monitor the student’s schoolwork, attendance, grades, etc., CUB requests access to your student’s accounts, if available.

Academic Monitoring*

	Username	Password	I am unaware of this information and I give permission to the CUB program to retrieve this information for me/my child from my school
Home Access
Schoology
Clever
Collegeboard.org

Student Participation Agreement
The following code of conduct outlines the behavior expected of me when I participate in all activities.
1. Keep a positive attitude.
2. Arrive mentally, physically, and emotionally prepared to work towards my goal.
3. Arrive on time and be where I belong at all times.
4. Treat others and myself with respect and courtesy.
Inappropriate behavior in the program will be addressed as follows:
- The first offense will result in a conference with the teacher/counselor/program manager and a phone call to the parent(s)/guardian(s).
- Participants may be excluded from attending field trips, work study program and other special events or activities.
- Continued inappropriate behavior could result in expulsion from the program.
Inappropriate Behavior:
- Displaying an uncooperative attitude towards program staff, guests, or fellow participants
- Foul language
- Disruptive behavior (ex. backtalk, sleeping during presentations or during class)
- Use of an iPod or cell phone even with headphones during classroom instruction
- Being disrespectful to a teacher, chaperone, staff member, and other participant, guest, or Delaware Tech staff.
- Excessive lateness (3-4 times)
- Scheduling and not showing up or canceling tutoring appointments without approval from CUB Staff
- Extreme violation of the respect and trust expected of program members
- Drinks and snacks brought into the computer lab
Issues Not Negotiable: These issues will result in immediate expulsion from the program.
- Fighting
- Use and/or possession of alcohol or drugs
- Use and/or possession of tobacco products
- Possession of any firearms and/or weapons
- Leaving campus without permission
Dress Code:
- No halter, midriff or tank tops (stomach and lower back should be completely covered)
- No sagging pants
- No short shorts
- No hats/caps in class
I have read and understand the expectations of being a program member and agree to accept the obligation of this Agreement.
Student Signature

Clear
Student Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian please initial here after reading*
Date*

MonthDayYear
mm-dd-yyyy

Student & Parent/Legal Guardian Contract
1. I agree to participate in all meetings with the Student Enrichment Coordinator at my high school.
2. I agree to attend all program classes punctually and regularly and to complete all academic and summer component class projects and assignments on time and to the best of my ability.
3. I agree to attend all tutoring sessions and bring all necessary classroom assignments with me to these sessions.
4. I agree to attend the six-week summer program.
5. I agree to give my full cooperation to the program staff.
6. I agree to provide a written excuse, signed by my parent or guardian, to the program office for any absence during the academic component and summer programs. I understand that I am expected to attend at least 80% of the academic component workshops and 80% of the summer program class/field trip days, unless an exception has been requested and approved.
7. I understand that no drugs (except by doctor’s prescription) or alcoholic beverages are allowed on campus. I also understand that smoking is prohibited. I further understand that once on the Delaware Tech campus I am not permitted to leave without consent from a program staff person. Violation of this rule (#7) will cause automatic dismissal from the program.
8. I understand that I must strive to achieve/maintain a minimum 2.5 GPA and that I will be placed on probation if I fall below that average. If my GPA falls below a 2.0, I may be dismissed from the program.
9. I understand that open drinks and snacks are not permitted in the Delaware Tech computer labs, hallways and lecture halls. Use of cell phones and iPods is prohibited in Delaware Tech classrooms and lecture halls. I understand that I am not permitted in the computer lab without an instructor present.
10. I understand that I will be paid a stipend during the academic and summer components according to my attendance. Lost or damage to program textbooks, equipment or facilities will require the partial forfeit of my stipend in order to reimburse the program for the replacement or repair cost. Any debts owed to Delaware Tech, the program and/or its committees will be deducted from my stipend.
11. I understand that I am not allowed to bring small children, friends, or visitors to program activities.
12. I understand that I must have on file, a signed parental consent form in order to attend all off-campus activities. I agree to ride only the program bus to all off-campus activities unless special permission is granted by the program manager.
13. Behavior problems and student responsibilities are fully described on the Participation Agreement.
14. I agree to provide access to my son/daughters Home Access Center, Schoology, Clever, Collegeboard.org accounts.
15. I agree to keep the program current regarding changes in my address, phone numbers and email address.
16. A parent or family representative will attend parent workshops and special events and will RSVP in a timely manner.
We, (Student){main_name} and (Parent){parent_name} understand that this is a Student & Parent/Legal Guardian Participation Contract between Delaware Technical Community College’s TRIO program, me and my parent/guardian. I hereby acknowledge that I have read, do understand, and accept the obligation of the contract. I further understand that my continued participation in this program is contingent upon my compliance to the aforementioned terms and conditions.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Delaware Tech TRIO Authorization Form
Participant Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Age*
School*
Grade*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone #*
(999)999-9999
Student's Cell Phone*
(999)999-9999
Student's E-Mail Address*
example@example.com
Mother's Name*

First NameLast Name
Mother's Place of Employment*
Mother's Email Address*
example@example.com
Mother's Cell Phone #*
(999)999-9999
Father's Name*

First NameLast Name
Father's Place of Employment*
Father's Email Address*
example@example.com
Father's Cell Phone #*
(999)999-9999

If parents cannot be reached call*

	Name	Relationship	Phone #
Emergency Contact 1
Emergency Contact 2

Family Physician*
Phone #*
(999)999-9999
Family Dentist*
Phone #*
(999)999-9999
Our child has the following health problem(s)*
Our child needs the following medication/health services*
Our child is allergic to*
Can the college provide your child with transportation to and from TRIO events?*

YesNo
Special needs of child during transportation provided by the college for TRIO events*
Medical Insurance
Medicaid Policy #*
Blue Cross/Blue Shield ID #*
Other: Name*
Other: Policy #*
In cases of emergency evacuation, is your child permitted to drive his/her vehicle off campus?*

YesNoNA
I, the undersigned legal guardian of {main_name} hereby give my consent to the Delaware Technical Community College for my child to attend and participate in all TRIO activities including, but not limited to, Workshops at Delaware Technical Community College, College Field Trips, College Fairs, Career Field Trips, Career Fairs, Leadership Conferences, Summer Programs, Academic Enhancement Trips, Delaware State TRIO Activities, Tutoring Activities, and Cultural Trips. My permission extends to all TRIO activities, including those off of property owned or controlled by the College, in which my child is a participant. My permission also includes the transportation that the College provides to my child for TRIO activities unless I have indicated otherwise on this form. In the event that I have declined to permit the College to transport my child to and from TRIO activities, I understand that it is my responsibility to arrange for my child’s transportation to and from TRIO activities and I acknowledge that the College, its employees, agents, and trustees, have no liability arising out of and from the transportation of my child to and from these TRIO events.

I understand that my child’s participation in TRIO activities carries with it the possible risk of physical injury, including serious disabling injury or even death, to my child. I acknowledge that my child has no physical or psychological problems that would prohibit his/her participation in TRIO activities, and I understand that my child is expected to follow the instructions of TRIO personnel during all TRIO activities. On behalf of my child, I expressly assume all such risk of physical injury or death and hereby release and will hold the Delaware Technical Community College, its trustees, employees and agents, harmless for any and all liability, including negligence actions, claims, debts and demands of every kind whatsoever which arise directly or indirectly from my child’s participation in the TRIO program and the transportation provided by the College for my child’s participation in TRIO activities. Moreover, I understand that I am fully responsible for any and all losses or damages that my child inflicts upon any person or upon property, whether on or off of College grounds, during my child’s participation in all TRIO activities.

In the event that I, my emergency contacts, or my family physician/dentist that I have listed on this form cannot be contacted in an emergency, I give my consent to Delaware Technical Community College to arrange for or provide all emergency medical and dental care necessary to preserve the health of my child during all TRIO activities, including while my child is being transported by the College to and from TRIO events. My consent also includes the transportation necessary for the College to preserve the health of my child. I acknowledge that I am responsible for all charges in connection with any care and treatment rendered. On behalf of myself and my child, I release Delaware Technical Community College, its trustees, officers, faculty, and employees from any and all claims arising from the emergency treatment and/or administration of medical care with respect to my child as well as from the transportation provided by the College to preserve the health of my child.

Moreover, I give Delaware Technical Community College consent to use the name, written work, and/or photograph/video of my child for inclusion in TRIO promotional, informational and other materials which the College or its staff in its sole discretion consider to be of benefit to the College and/or the TRIO program. This includes (but is not limited to) newspaper, television, and brochures. On behalf of my child, I waive the right to approve such uses and I release Delaware Technical Community College, its trustees, employees, and agents, from any liability in connection therewith.

I HAVE CAREFULLY READ ALL OF THE INFORMATION ON THIS FORM AND VOLUNTARILY AGREE TO ALL TERMS AND CONDITIONS. I AM THE LEGAL GUARDIAN OF THE TRIO PARTICIPANT, AND I UNDERSTAND THAT THE INFORMATION, TERMS, AND CONDITIONS CONTAINED ON THIS FORM SHALL SERVE AS A RELEASE AND ASSUMPTION OF LIABILITY FOR MY HEIRS, EXECUTORS, AND ADMINISTRATORS.
Parent/Legal Guardian Signature*

Clear
Parent/Legal Guardian Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy