PERSONAL INFORMATION

FAMILY INFORMATION

Father's Information

Mother's Information

If you are living with someone other than your parents, please complete the following:

PERSONAL INTERESTS

STUDENT ESSAY

PARENTAL RELEASE, PERMISSION, AND SIGNATURE FORM

Permission to Release:

I hereby grant permission for my child, _______________, to participate in Central State University’s Upward Bound Program if he/she is selected. I also give my child permission to participate in all programs and activities, including the summer residence session, sponsored by CSU Upward Bound. In consideration of the activities provided to my child, I hereby release Central State University/Upward Bound, and their employees from any claims for injury or damages arising out of my child’s participation. I also accept responsibility for my child’s conduct while participating in Upward Bound, and release Central State University and Upward Bound from liability for injuries or damages resulting from my child not following and adhering to the program policies

Permission for Release:

I hereby grant permission for Central State University Upward Bound to have access to and to receive copies of my child’s academic records. And in accordance with federal mandates, I hereby grant permission for Central State University Upward Bound to have access to and receive copies of my student’s academic records through post-secondary education. I understand that the U.S. Education Department requires this information to determine the overall effectiveness of the Upward Bound Program.

MINOR STUDENT MEDIA RELEASE

I, _____________, parent/guardian of _______, a minor student of the Central State University Upward Bound programdo hereby give permission to Central State University Upward Bound, to use my child’s photograph or photographic image, name, birth date, honor roll information and voice recordings in official CSU Upward Bound business, including: CSU Upward Bound Web sites, CSU Upward Bound newsletters and newspapers, CSU Upward Bound videos, and other print and electronic materials as deemed appropriate by CSU Upward Bound staff. I understand that Central State University requires that all minor students who have agreed to pose for a photograph for use in the promotion of Central State University and its departments/units must sign a photograph release form (along with his or her parent). It is agreed that the use of my photograph or photographic image shall in no way be used in any other forum other than for official University/Upward Bound business.

In consideration of my child’s engagement as a model, and for other good and valuable consideration herein acknowledged as received, I hereby grant to Central State University and assigns, those acting with its authority and permission, the irrevocable and unrestricted right and permission to copyright, in its own name or otherwise, and use, re-use, publish, and re- publish photographic portraits or pictures of my child or which my child may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my child’s own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at his studios or elsewhere, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to the use of any printed matter in conjunction there with.

I hereby waive any right that I may have to inspect or approve the finished product and the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied.

I hereby release, discharge, and agree to save harmless Central State University and assigns, and all persons acting under its permission or authority or those for whom acting from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

I do hereby release, acquit and forever discharge the State of Ohio, Central State University, its officers, employees, attorneys, representatives, insurers and assigns from any and all demands, cause of action and/or judgments of whatsoever nature of character, past or future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credit, refunds, or any other monies due or to become due, or damages of any kind or nature, and whether arising from common law or statute, arising out of, in any way, the use of my child’s photograph, photographic image, name, birth date, honor roll information and voice recordings for official University business.

This release contains the entire agreement between the parties and shall be binding upon and inure to the benefit of the successors and assigns of the undersigned.

Income Eligibility

One of the criterion for eligibility to the Upward Bound Program is based on income, as required by the U.S. Department of Education, please attach a copy of pages one and two of your most current 1040 federal income tax return statement (we need to see the list of dependents on page one and the line which states “Taxable Income” on page two). Make sure your signature and the date are on the bottom of page two of form 1040.

If you are not employed outside of the home, and you are not required to file taxes, please attach documentation from the U.S. Department of Human Services for income verification.

Special Note

The personal information you provide for the Upward Bound Program may be sent to the federal government. The information is protected by the Privacy Act. No one may see the information unless they work with or for the Upward Bound Program or are specifically authorized to see the information. The information is necessary to determine if your child is eligible to participate in the program and it aids the government in measuring the program’s effectiveness. The U.S. Department of Education has authority to gather information to help make Upward Bound a better program (10 USC 1231a). If you do not make the necessary information available to the Upward Bound Program and the Department of Education, you cannot receive any benefits from the Program.

I declare that the information provided on this application is true to the best of my knowledge.

Applicant, make sure you have. . .

• Completed all blocks in the personal information section of the application
• Completed the student essay
• Applicant’s and the principal’s or guidance counselor’s signature
• A copy of your most current grade card
• Requested a transcript with Ohio graduation test results from your current school
• Parental Release, Permission, and Signature Form on page 4 completed and signed
• Minor Student Media Release Permission Form completed and signed
• Two Teacher/Counselor Recommendation Forms completed by your school
• Included the required income eligibility information as explained on page 8: signed copies of page one and two from parent/guardian’s most recent IRS 1040 tax form or U.S. Department of Human Services
  documents.
• Parent/Guardian signature and date

DRESS POLICY

Upward Bound Program
Students participating in the Central State University’s Upward Bound Program will abide by the rules, regulations, and policies previously established to foster academic excellence, outstanding character, leadership ability, and the endurance to succeed. This dress policy is a mandatory policy and is directly connected to your continued success within the Upward Bound Program. As we learn and grow as an academic body we must learn how society adapts to rules and regulations in different environments.

Our main focus is academics. Our corresponding goals are: respect, learning how to deal with diverse communities and people, broadening our cultural knowledge, exercising flexibility, learning how to communicate effectively, and encouraging each other to succeed. We do not succeed when we are not focused on presenting ourselves in a positive manner. Adaptability to different classes, cultures and customs will help you in succeeding as much as having a high grade point average or a high paying job. The Upward Bound Program at Central State University will hold every one accountable for dressing to succeed. It is our hope that this Dress Policy is a guide to understanding that
sometimes you are what you wear. Please be advised that at any Upward Bound Event each participant should be dressed appropriately for each specific event. If you are not sure how you should dress for any event, please do not hesitate to call the office.

Generally the following rules should apply:

• Casual dress means: regular school dress code with no skin showing. That is neither torso or backsides
  or underwear exposed. All shirts should cover your waist line and all pants should not be sagging below
  your waistline.
• Business Attire means: Males: dress slacks, shirt and tie or suit; Females: Dress slacks or skirt and a
  blouse, a dress, a skirt set, or suit.
• Business Casual means: Dockers, khakis, or jeans, no t-shirts, no flip flops.
• Never should any of the following be worn during an Upward Bound event: doo rags, scarves, wrap cloths, hats, sunglasses in doors.

Dayton Public Schools-Code of Conduct Policy 2009-2010

Dress Code Dressing or grooming in a manner that disrupts the teaching or learning of others as determined by local school communities; including, but not limited to, ski masks; hats; doo rags; bare midriffs; clothing with drug, alcohol, sex, vulgar or hate messages; skirts or dresses above mid-thigh; pants worn below the waist line; or any full-face covering(s) are prohibited. This also includes failure to follow uniform dress code in applicable buildings (www.dps.k12.oh.us).

As a participant in the Central State University Upward Bound Program, I agree to fully participate in the program and abide by the rules listed above. I understand that continued failure to do so may result in dismissal from the program.

BEHAVIOR POLICY

Upward Bound Program
Students participating in the Central State University’s Upward Bound Program will abide by the rules, regulations and policies previously established to foster academic excellence, outstanding character, leadership ability, and the endurance to succeed. This behavior policy is a mandatory policy and is directly connected to your continued success within the Upward Bound Program. As we learn and grow as an academic body we must learn how society adapts to rules and regulations in different environments.

Our main focus is academics. Our corresponding goals are: respect, learning how to deal with diverse communities and people, broadening our cultural knowledge, exercising flexibility, learning how to communicate effectively, and encouraging each other to succeed. We do not succeed when are focused on the small picture, complaining, disrespecting each other, prejudging, and not paying attention. Adaptability to different classes, cultures and customs will help you in succeeding as much as having a high grade point average or a high paying job. The Upward Bound Program at Central State University will hold every one accountable for the behavior they exhibit. It is our hope that this Behavior Policy is a deterrent to unacceptable behaviors. Some unacceptable behaviors consist of:

• Being late for events
• Not attending events
• Being improperly dressed for events
• Failure to respond to redirection
• Talking while the speaker is speaking, whether it is a visitor or one of our own
• Playing during a presentation
• Using your cell phone or electronic equipment during a presentation, lecture, or performance
• Walking out during an event
• Running
• Sleeping in class, or during events, workshops, etc.
• Shouting
• Hitting
• Laughing at inappropriate times
• Any other actions or body language that could exclude you from being invited back

Commitment promotes rewards; poor behavior produces limited outcomes. Any behavior by a participant that is deemed inappropriate and detrimental to the core values of academic success will receive a verbal warning, a counseling session as a written warning, and any repeated offenses will result in the reduction of your monthly stipend and can/will result in dismissal from the program.

ATTENDANCE POLICY

Upward Bound Program
The United States Department of Education via its Trio Programs incorporates a mandatory attendance policy in its programs. The Central State University (CSU) Upward Bound Program (UBP) as a Trio funded program therefore supports and enforces the following attendance policy.

Our Attendance Policy covers all events sponsored by CSU UBP: tutoring, field trips, Saturday workshops, parent meetings, college trips, cultural events, assessments, appointments, recruitment and any assigned event.

Parent Meetings are mandatory for parent and participant. Incorporating the whole family aids the success of the participant. Trio funding requires parents to attend parent meetings; we in addition encourage that you attend all special events as your time allows. Notification is required if you will not be able to attend.

Weekly Tutoring is mandatory. Tutoring will average about four sessions a month. Due to holidays and longer months it may vary from 3-5 sessions per month. Absences must be reported in advance when applicable. Documentation will be needed to excuse the absence. Reasonable absences are: doctor’s appointments, family emergencies, and absence from school. All absences must be documented. The following consequences will be effect for failing to attend tutoring sessions:

• 4 of 4 for the month      Full Stipend               $20
• 3 of 4 for the month      Reduced stipend       $15
• 2 of 4 for the month      Reduced stipend       $1
• 1 of 4 for the month      No stipend.               $0
• Reduced study habits
• Missed assessments
• Missed support
• Missed opportunities
• Missed information

This policy is in place to reinforce that decisions have consequences. Please commit to your educational goals and attend all assigned sessions. As a participant in the Central State University Upward Bound Program, I agree to fully participate in the program and abide by the rules listed above. I understand that continued failure to do so may result in dismissal from the program.

Tutoring Commitment Form

STUDENT'S COMMITMENT:

This tutoring commitment agreement confirms that I am committed to my own academic success. I sincerely believe that I am college material and desire to become __________. I have agreed to participate in the Upward Bound Program to achieve my higher education goals.

Therefore I agree to the following:

1. To decide to attend tutoring sessions weekly
2. To sign in and out of tutoring
3. To bring my assignments to tutoring and complete them
4. To use my tutoring time to complete assignments, to study, or to complete Counselor assigned projects
5. To request assistance when I need it
6. To remain on task and respect the time and space of others
7. To demonstrate academic progress
8. To participate in required activities

ACADEMIC COUNSELOR’S COMMITMENT:
1. To maintain and document your attendance
2. To encourage your academic and personal goals
3. To hold you accountable for your behavior
4. To report your absences to your Parents and the Director
5. To work extremely hard to provide information that is helpful and relevant
6. To design study material that prepares you for college
7. To tutor in all subject areas
8. To Remember your good qualities at all times

Students participating in the Central State University’s Upward Bound Program will abide by the rules, regulations and policies previously established to foster academic excellence, outstanding character, leadership ability, and the endurance to succeed. Attendance is a mandatory policy and is directly connected to your stipend availability. Commitment promotes rewards; absences produce limited outcomes. Any absence must be reported a week in advance. Any two unreported absences will result in the reduction of your monthly stipend. Continued absences can/ will result in dismissal from the program.

CELL PHONE/ELECTRONIC EQUIPMENT USAGE POLICY

Electronic equipment may be identified as: iPods, MP3’s, audio plugs, cameras and any other general electronic equipment that will not be conducive to a learning environment.

Cell phone/electronic equipment use is prohibited during classes, meetings, tutoring, while on field trips, and any time during activities where your safety may be an issue.

Cell phone/electronic equipments may be used during break times, free times, and in your dorm rooms.

Failure to comply with this Cell phone/electronic equipment policy will result in the following consequences:

• 1st offense the cell phone/electronic equipment will be taken for duration of tutoring session.
• 2nd offense the cell phone/electronic equipment will be taken for the duration of the tutoring session. A written counseling will occur. Your parents will be notified.
• 3rd offense the cell phone/electronic equipment/electronic equipment will be taken for the duration of tutoring. The amount of $10.00 will be taken from your monthly stipend. Your parents will be notified.

Remember that your property is your responsibility and that Upward Bound is not responsible for the safety of your electronic property.

As a participant in the Central State University Upward Bound Program, I agree to fully participate in the program and abide by the rules listed above. I understand that failure to do so may result in dismissal from the program.

PARENT'S COMMITMENT FORM

PARENT'S COMMITMENT:

This parent’s commitment form confirms that I am committed to my child’s academic success. I sincerely believe that she/he is college material and can become _______. I have agreed to participate in the Upward Bound Program to help my child achieve their higher education goals. Therefore I agree to the following:

1. To encourage my child to attend tutoring sessions weekly
2. To inquire about her/his tutoring attendance
3. To instruct my child to take homework assignments to tutoring
4. To attend all scheduled parent’s meetings with my child
5. To request assistance when I need it
6. To provide transportation for my child to activities and meetings
7. To advocate for the success of my child
8. To participate in required activities
9. To volunteer for activities as needed
10. To be proactive in my child’s success

UPWARD BOUND’S COMMITMENT:
1. To maintain and document your attendance
2. To encourage your child’s academic and personal goals
3. To support you and your student through the college prep and college admission process
4. To report any absences to you
5. To work extremely hard to provide information that is helpful and relevant
6. To keep you informed on the progress of your student
7. To advocate and educate you and your student on issues that affect your success
8. To remember your good qualities at all times.

Students participating in the Central State University’s Upward Bound Program will abide by the rules, regulations and policies previously established to foster academic excellence, outstanding character, leadership ability, and the endurance to succeed. Parent participation and attendance is a mandatory policy through the U.S. Department of Education and is directly connected to the success of your child. Commitment promotes rewards; absences produce limited outcomes. Any absence must be reported a week in advance. Any two unreported absences will result in the reduction of the student’s monthly stipend. Continued absences can/ will result in dismissal from the program.

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

CONSENT

In the event of an emergency where medical aid and/or treatment is required, due to illness or injury during the course of participation in the program, I authorize Central State University Upward Bound to:

1. Secure and retain medical treatment and transportation if needed

2. Release participant’s name and pertinent records/information to the authorized individual or agency involved in the medical emergency treatment

In the event I cannot be reached:

NON-CONSENT

I do NOT give my consent for emergency medical aid and/or treatment in the case of illness or injury during the participation in the Upward Bound program or while being on the Central State University premises. In the event that emergency medical treatment and/or aid is required, I wish the following procedures to take place:

TRAVEL CONSENT

This document is to certify that my child is authorized to travel on all Upward Bound Program sponsored trips in vehicles supplied by the Upward Bound Program for the entire period in which my child is enrolled in the program. I understand that the Upward Bound Program and Central State University will not be responsible when my child chooses to ride in vehicles not officially provided by Central State University’s Upward Bound Program.

PARENTAL EDUCATION VERIFICATION

PARTICIPANT CITIZENSHIP VERIFICATION

I also attest that my child (participant) stated above is a citizen of the United States of America.

UPWARD BOUND PROGRAM
TERMINATION POLICY

The United States Department of Education via its Trio Programs incorporates a mandatory attendance policy in its programs. The Central State University (CSU) Upward Bound program (UBP) as a Trio funded program therefore supports and enforces the following termination policy.

As a participant in the Central State University Upward Bound Program, I agree to fully participate in the program and abide by the rules listed above. I understand that continued failure to do so may result in dismissal from the program.

Failure to attend scheduled meetings and functions can result in termination from the program. Termination is defined as no longer eligible for the program. A participant can be terminated for the following reasons:

• Required documents and verifications not in the file within 30 days from notice
• Failure to attend a single function within a 30 day period
• Deliberate harassment and violations of established rules and policies
• Voluntary withdrawal from the program in writing
• Not enrolled in a target school
• Misrepresentation on your application
• Mailing address not updated within 30 days

It is our hope to retain every student we enroll. Please contact the office if you have concerns or any situations that you feel may interfere with your success in the program. We want to support and empower your success.

TAX INFORMATION