Please read each question carefully, check the appropriate boxes, and sign in the appropriate spaces. Please print or type legibly

I hereby certify that the information provided for program enrollment is accurate and complete.

The Federal Privacy Act protects the personal information provided on the CCBC Dundalk Upward Bound Program application. The information is required by the U.S. Department of Education to determine eligibility. Additionally, the Department of Education has the authority (20USC 1231a) to gather information on all Upward Bound Program participants to monitor their progress. No one may see any information on the application unless they work for the program or are specifically authorized to see the information.

Please attach to this application a copy of your most recent 1040 or 1040A tax return (front and back) or a written letter from a government agency indicating source of financial support.

I hereby certify that the information provided for program enrollment is accurate and complete.

I, {parenguardian83} , give consent for the following:

1. To allow {nameOf} to participate in the CCBC Dundalk Upward Bound program.

2. To release school records, transcripts, and all information relative to my son’s/daughter’s academic and personal performance to the CCBC Dundalk Upward Bound Program for the purpose of assessment and evaluation.

3. To allow my son/daughter to be referred to emergency medical services if needed during his/her enrollment in the program.

4. To allow my son/daughter to use transportation provided by the CCBC Dundalk Upward Program during program activities.

This consent hereby releases the CCBC Dundalk Upward Bound Program, its program personnel, The Community College of Baltimore County, the Dundalk Campus, and any affiliates associated with the program and/or college from liability or medical expenses incurred in the event of an accident. I understand that I will be contacted in a timely manner in the event of an emergency or accident.

1. I hereby authorize {nameOf93} {address95}

To release information concerning: {name}

I understand that the recipient of the record(s) will use the material for legitimate interests only and that the information contained therein shall not be further disclosed to any other party or agency without my prior written consent, except as authorized by federal and state laws under authority of the Family Educational Rights and Privacy Act, 20 U.S.C. §1232G.

NOTE: All material contained in the student’s record is accessible to the student and/or the parent(s) subject to applicable policies of the Board of Education of Baltimore County.

The CCBC Dundalk Upward Bound Program will serve as an intensive enrichment program designed to enhance the academic and personal growth of participants whereby, they will enter and persist in a program of post-secondary education, moving from promise to purpose to power.

The participant will abide by the rules and regulations of the CCBC Dundalk Upward Bound Program which include, but is not limited to the following: attend and participate in all classes and tutorial sessions, complete and turn in all assignments from teachers, tutors, counselors, and/or CCBC Dundalk Upward Bound personnel, perform at a minimum grade level as defined (2.0), attend all required activities, and follow the code of conduct as ascribed by Baltimore County Public Schools.

Violation of any of the provisions outlined above will result in a review of the student’s ability to function effectively in the CCBC Dundalk Upward Bound Program. The right to determine the serious nature of an offense remains with program personnel. There are three stages of disciplinary actions to be taken in the event an offense is committed.
They are as follows:

• For an academic violation, the following steps will be taken: 1) participant conference; 2) parent(s)/guardian(s) conference; 3) guidance office and school notified; 4) participant scheduled for additional tutoring sessions. If participant is unable to comply a three-day suspension will be imposed; or 5) restriction of access to free time and/or extra-curricular activities.

• For a behavioral violation, the above steps will be taken, excluding. If the behavior continues the participant will be expelled
from the program. The opportunity for reinstatement will be addressed on a case-by-case basis.

As a parent/guardian; I agree to participate in all required CCBC Dundalk Upward Bound Program activities and to attend orientation and parent/guardian workshops during the academic-year and summer components. Parent(s)/guardian(s) are encouraged to be active participants in his or her child’s academic and personal/social progress.

I have read and agree to what has been stated above. In the event I am unable to retain my commitment, I will notify the CCBC Dundalk Upward Bound Program staff as soon as possible.

Choose one of the following essay questions. TYPE a 250-500 word essay and attach with your completed application.

1. Describe the most challenging obstacle you have overcome. How did this impact your life and what did you learn from this experience?

2. What do you hope to gain from being a part of this program? What attributes can you offer to this program?

3. Considering your lifetime goals, discuss how your current and future academic and extra-curricular activities might help you achieve your goals.

4. Describe a setting in which you have collaborated with people whose experiences and/ or beliefs differ from yours. Address your initial feelings and how those feelings were or were not changed by this experience.