Davidson County Community College-UB-Application Form

Davidson-Davie Community College Upward Bound

2024-2025 Student Application Packet

* Indicates required information
Si desea ver el formulario en español, cambie el idioma en la esquina superior derecha.

Program Overview
PROGRAM OVERVIEW

Upward Bound (UB) is funded by the U.S. Department of Education and is designed to motivate and prepare high school students for college. It’s a year-round program which provides educational services to selected 14 to 18-year-old participants. The program strives to increase academic preparation for college, and increase rates of high school graduation, as well as college admission and graduation.

Eligibility

Upward Bound is for students who meet federal income and parent education guidelines. Applicants are high school students, enrolled in rigorous coursework and on a "college track." (See your high school counselor for advisement or questions.) Selected applicants should also be committed to completing the 2025 six-week Summer Academy.

2024 – 2025 Application Guidelines

Applicants must submit the following documents:
- Completed and Signed 2022-2023 Upward Bound Application
- Copy of your High School Transcript or Report Card (for 9th grade students)
- Copy of your current Class Schedule
- Teacher/Counselor Recommendation
Submit the completed and signed application via mail to the address below or to the school’s guidance/Upward Bound offices, to the attention of the Upward Bound Coordinator. Applications will not be considered unless the entire packet is complete.

Davidson-Davie Community College

Upward Bound Program

P.O. Box 1287 · Lexington, NC 27293

336.249.8186 ext. 6302 – Fax: 336.248.6714

upwardbound@davidsondavie.edu

Part 2: School Information
PART 2: SCHOOL INFORMATION
Current School*
Current GPA*
Current Grade*

9th10th11th12th
School ID #
Are you Taking Any of the Following Classes*

Accelerated or HonorsAPCollege Credit ClassNone of the above

Part 5: Student's Medical Information
PART 5: STUDENT'S MEDICAL INFORMATION
Does your Child have any Allergies?*

YesNo
If yes, please list:*
Does your Child have a Physical Impairment, Medical Condition or Disability?*

YesNo
If yes, please list:*
Is your Child Taking any Type of Prescriptions?*

YesNo
If yes, please list:*

Part 7: Guardian/Student Consent
PART 7: GUARDIAN/STUDENT CONSENT
Student's Name*

First NameLast Name
School*
Consent for Services:

I understand pre-college and educational outreach services including but not limited to: academic advising, tutoring referrals, cultural enrichment activities, career and college exploration; will be provided as needed. Services are provided by Upward Bound (UB) staff (counselors, volunteers, mentors, tutors and teachers), and are designed to help students achieve their academic and personal goals. These services are provided free of charge and at the student’s will.

ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA).

Release of Information:

I authorize Upward Bound to access academic and personal information in the legitimate educational interest of my student including but not limited to: public assistance, free & reduced lunch documentation, standardized test scores (state testing scores, SAT, ACT, GED), report card, unofficial transcripts, official transcripts, attendance records, information about the status of post-secondary education admission/enrollment, financial aid documentation (including FAFSA pin code, Student Aid Report, and award letters) in accordance with The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99). I understand this information is essential in assisting me/my child in preparation for post-secondary education.

I further understand all information received is for UB use only and is held strictly confidential.

I understand that I am giving the Davidson-Davie Community College Upward Bound Program’s Director, Student Success Advisor, and office manager permission to access my student’s grade and attendance information directly from appropriate school personnel and to request other academic and behavioral information directly from school staff. I give permission for Upward Bound to access and collect this information for the duration of my student’s participation in the program and throughout his or her high school and college career; however, if I choose to withdraw this permission, I can call the Upward Bound Program Director at Davidson-Davie Community College (336-249-8186 ext. 6420) or with the Upward Bound Student Success Advisor at my child’s school.

Behavior Agreement:

I understand that the rules I am held responsible to at my school campus are the same rules that apply during any event with the Upward Bound Program. If any rule is broken I understand if it becomes necessary, the UB staff will call my parents and they will be required to pick me up IMMEDIATELY. I also understand that failure to abide by any of the recognized rules may result in my dismissal from the Upward Bound Program.

I authorize DDCC TRIO Upward Bound to send communication via email, text message, school messenger, REMIND App to my email, students email, cell phone, student cell phone, or home phone. I understand that text messaging rates may apply to any text messages received. I also understand that I or DDCC TRIO Upward Bound may revoke this permission in writing at any time. I agree not to hold DDCC TRIO Upward Bound liable for any electronic messaging charges or fees generated by this service. I further agree that in the event emails, cell phone and other information changes, that I will inform DDCC TRIO Upward Bound.

Communication Release:

I, {studentsName} ,authorize DDCC TRIO Upward Bound to send communication via email, text message, school messenger, REMIND App to my email, students email, cell phone, student cell phone, or home phone. I understand that text messaging rates may apply to any text messages received. I also understand that I or DDCC TRIO Upward Bound may revoke this permission in writing at any time. I agree not to hold DDCC TRIO Upward Bound liable for any electronic messaging charges or fees generated by this service. I further agree that in the event emails, cell phone and other information changes, that I will inform DDCC TRIO Upward.
Image (Media) Release: (Please read carefully)*

I DO give UB permission to use my child’s picture/image and/or accomplishments as a result of my child’s participation in the program. These images/pictures may be used on program brochures, flyers, social media accounts, and/or be published on the program’s website. I release any claims against Davidson-Davie Community College, the UB Program and/or its staff for any damages, awards, claims or liabilities which may arise from any unauthorized use or copyright violations of my child’s image, picture or work.I DO NOT give UB permission to use my child’s picture/image and/or work or drawings as a result of my child’s participation in the program. These images/pictures may not be used on program brochures, flyers, social media accounts or be published on the program’s website. I release any claims against Davidson-Davie Community College, the UB Program and/or its staff for any damages, awards, claims or liabilities which may arise from any unauthorized use or copyright violations of my child’s image, picture or work.
Emergency Contacts:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
(999)999-9999
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
(999)999-9999
Waiver of Liability

As parent and legal guardian of the above-mentioned student, I authorize and permit my child to participate in field trips, activities, and events offered by the Upward Bound Program. I understand that my child may be leaving his/her school campus or Davidson-Davie Community College (DDCC) and may be transported by the Upward Bound staff of DDCC. I agree that DDCC, Upward Bound, and anyone associated with DDCC will not be held liable for any loss, injury, or death related to any field trips, or events. Further, I agree to hold DDCC, Upward Bound, officers, staff, and volunteers, harmless from any claims whatsoever occasioned in any of the situations that I have agreed, that Upward Bound at Davidson-Davie Community College shall not be held liable.

In the event that my child, {studentName88}, is involved in a medical emergency, I authorize the Upward Bound staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc.) if they are unable to contact me for verbal authorization.
Student Name*

First NameLast Name
Insurance Name and Number
Medicaid Card
I agree to promote my students' participation in the academic year and Summer Academy. I will attend parental involvement activities that will encourage my son/daughter to complete the program, and be prepared for college.

I certify to the best of my knowledge all of the above information contained in the application is true, and correct.
Student*

First NameLast Name
Student Signature*

Clear
Use your mouse or finger to click and drag to sign the form
Date Signed*

MonthDayYear
mm-dd-yyyy
Guardian Name*

First NameLast Name
Guardian Signature*

Clear
Use your mouse or finger to click and drag to sign the form
Date Signed*

MonthDayYear
mm-dd-yyyy