STUDENT INFORMATION

ACADEMIC INFORMATION

FAMILY INFORMATION

Father or Male Guardian

Mother or Female Guardian

INCOME INFORMATION

Please note that the above applies only to families who filed taxes. You must attach a copy of your most recent completed and signed federal tax form (1040, 1040A, or 1040EZ) to this application.

You must submit photocopies as proof of income for each of the above sources of income that apply to your household. 

• For wages, attach the tax form to this application. 
• For other sources, the award letter that tells you the amount you will receive needs to be attached to this application.

STUDENT AND PARENTAL RELEASES/AGREEMENTS

Carefully read the following release information, which will allow the Upward Bound Math Science program to fully provide useful services to the students. Personal information obtained by the Upward Bound Math Science program staff is available to the US Department of Education, which has the authority to gather information to help make Upward Bound Math Science a better program. This information is protected by the Family Educational Rights & Privacy Act (FERPA). No one may see this information unless they work with the Upward Bound Math Science program. Signatures are required except when stated otherwise.

LIABILITY RELEASE

I release and hold harmless the Kentucky Community and Technical College System, Southeast, its Board of Trustees, agents, officers, and/or employees from any and all claims, demands, causes of action or damage which may accrue on account of bodily or personal injury, property damage or death suffered by my child arising out of his/her participation in Southeast’s Upward Bound Math Science program.  I hereby assume any and all risks attendant to my child’s participation in Southeast’s Upward Bound Math Science program.

STUDENT PARTICIPATION AGREEMENT

If accepted for participation in the Upward Bound Math Science program, I agree to participate fully in all scheduled activities and abide by the rules and regulations of the program.  I will attend all Saturday Sessions on campus in addition to counseling sessions and scheduled tutoring sessions at my school during the academic year, which runs August through May.  I will enroll in the pre-college curriculum in high school.  If eligible, will attend the six week Summer Academic Residential Session, which runs during June and July, and will participate in all activities, classes, counseling sessions, and tutoring.  I understand that the only way I may be excused from any of the above is through verified sickness, family responsibility, emergency, or school scheduled activity.  I understand that I must notify the Upward Bound Math Science staff in advance when I have previous knowledge that I am to miss a meeting or scheduled activity. 

I understand that there is a 60 day probation period and that the Director has the right to dismiss any student whose behavior is incompatible with the goals and standards of Upward Bound Math Science, Southeast, or the Kentucky Community and Technical College System at any time.

RELEASE PICTURE / VIDEO INFORMATION
(Optional)

I hereby give permission for my child’s photograph to be taken in connection with activities of the Upward Bound Math Science program at Southeast. I agree to allow the Upward Bound Math Science program at Southeast to release, for educational purposes, photographs and video recordings, with or without audio, of program activities and projects involving the students and my child. I further give Southeast’s Upward Bound Math Science program permission to release my child’s name, photograph, and work product, written or otherwise, to newspapers and other media sources, including television, in connection with school activities, awards and honors, and also to release them for institutional development and promotional purposes.

ACCESS TO RECORDS / PERMISSION TO TEST 

I hereby grant consent for the Upward Bound Math Science program staff from Southeast to have access to any information they request from my child’s school records.  This includes, but is not limited to, the cumulative record folder, grading period report cards, and any transcripts. 

I hereby grant consent for the Upward Bound Math Science program staff from Southeast to administer or request all testing of my child deemed necessary and appropriate to meet the goals of the program.  I understand that this testing may include: diagnostic, academic, achievement, aptitude, interest inventories, and other types of tests recommended by the Upward Bound Math Science staff.  I further understand that any information obtained will not be released to any other organization without my permission.

This information will be used in providing services to the students and in collecting aggregate data for research purposes.  All information will remain confidential.  This release remains valid throughout my child’s time in high school or as a member of the Upward Bound Math Science program.

AUTHORIZATION TO RELEASE HIGH SCHOOL AND POST-SECONDARY INFORMATION

I hereby authorize the Southeast Upward Bound Math Science program or its authorized representative(s) or employee(s), bearing this release or copy thereof, to obtain any information in my files pertaining to my educational records including but not limited to academic information and achievement, attendance, athletic, persona history, and disciplinary records, grade reports and information, official transcripts, academic plans, class schedules, academic standing, degrees or certificates completed, and financial aid awards received, including the FAFSA (financial aid application). 

This authorization expires six years after entering a post-secondary institution.

I agree to hold Southeast’s Upward Bound Math Science program harmless for any information that is obtained prior to the termination date of this signed Authorization to Release Information.

I understand that Upward Bound Math Science is a TRIO program, federally funded by the US Department of Education.  In order to validate the success of these programs, the US Department of Education requires all Upward Bound Math Science programs to continue tracking their students through post-secondary education and to annually report on their progress.

ADDITIONAL DOCUMENTS

Please attach the following documents: