California Polytechnic State University-UB-Application Form

Upward Bound Student Application
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PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN 1 INFORMATION
Name of Parent/Guardian #1*

First NameLast Name
Relation to Student*
Phone*
(999)999-9999
Email
example@example.com
Education Level*

Less than High SchoolHigh SchoolSome College4 year degree or more
PARENT/GUARDIAN 2 INFORMATION
Name of Parent/Guardian #2

First NameLast Name
Relation to Student
Phone
(999)999-9999
Email
example@example.com
Education Level

Less than High SchoolHigh SchoolSome College4 year degree or more

MEDICAL/EMERGENCY INFORMATION
MEDICAL/EMERGENCY INFORMATION
First Parent or Guardian to Contact Immediately in Case of Emergency*
Alternate Parent or Guardian to Contact in Case First is Unavailable*
Policy Holder's Name*

First NameLast Name
Policy Number*
Insurance Company Name*
Group Number
Insurance Company Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company Phone Number
(999)999-9999
Medical History of Student: *Please list details regarding medications that student is taking, and any other current or past medical conditions that may require treatment. List/describe any physical restrictions:*
Authorization for Medical Treatment *My student has the permission to participate in events and activities supervised by Upward Bound (UB). Furthermore, should my student require medical attention and/or care while participating in UB, I give my consent to medical examination and necessary treatment, including drugs, x-rays, and surgery as may be deemed necessary by the attending physician. This consent shall remain effective so long as my student is a participant in UB. Should an emergency arise, staff will attempt to reach me and be guided by my wishes. In the event that I cannot be contacted, the attending physician has my consent to act as medical judgment may indicate.*

Yes
Liability Waiver: *I agree to waive all claims against the Upward Bound Program, California State University, Cal Poly Corporation, and the Foundation that may result from my child’s participation in Upward Bound, either on a field trip, during the summer residential program, during a Saturday session, or in any other capacity.*

Yes
Please read and enter your name below signifying that you agree with the following statement:

I/We give permission for my/our student to participate in the Upward Bound (UB) program at Cal Poly and allow UB to access any school or financial records of my student to determine: eligibility for the program; status and progress in middle, secondary and post-secondary education; and eligibility for financial aid. In addition, I give my permission for my child's name, photograph, work and/or statements to be used by UB for promotional, publicity or instructional purposes in print and/or electronic formats.

All information provided in this application is accurate to the best of my knowledge.
Student Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name