DIRECTIONS: This form must be completed by the student and the parent/guardian.
The U.S. Department of Education requires that the Upward Bound Academy Program at Kansas City Kansas Community College follow and monitor the academic progress of students participating in UB by tracking secondary school graduation, college matriculation, persistence, and subsequent college graduation, etc.
In consideration of {studentName} being accepted for participation in the Upward Bound Academy program at Kansas City Kansas Community College, I/we hereby specifically authorize all secondary and post-secondary institutions attended by {studentName} to release the following information to representatives of the Upward Bound Academy program at Kansas City Kansas Community College.
Secondary Schools:
- Achievement, aptitude proficiency, state assessments, and interest scores (ACT, PACT, SAT, PSAT, Iowa Test of Basic Skills scores and all other tests taken since 7th grade)
- Official transcripts
- Official copies of report cards
- Activities chart or lists of extra- or co-curricular activities
- Family background data
- Interview information from school administration, counselors, and teachers Health Related information during the summer non- residential program.
Post-Secondary Schools:
- Enrollment verification information
- Transcripts or transcript information documenting academic progress
- Degree attainment information
- Interview information from school administrators
This permission is granted for a period not to exceed ten (10) years after secondary school graduation or until this authorization is specifically cancelled by both {studentName} and his/her parent or guardian.
As a result of signing this form, the student applicant and his/her parent/guardian certify that they are providing this authorization with full understanding and voluntarily in consideration of the student applicant’s participation in the Upward Bound Academy program at Kansas City Kansas Community College and to permit the program to fulfill requirements imposed by the U.S. Department of Education, the funding agency.