Please read each question carefully, check the appropriate boxes, and sign in the appropriate spaces using your computer mouse or a stylus.

Answer the question below to the best of your ability. Make sure your response includes all aspects of the question and is between 125 -150 words.

The Federal Privacy Act protects the personal information provided on the CCBC Upward Bound Catonsville 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.

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

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

1. To allow {nameOf} to participate in the CCBC Upward Bound Catonsville Program.
2. To release school records, transcripts, and all information relative to my son’s/daughter’s academic and personal performance to the CCBC Upward Bound Catonsville Program for the purpose of assessment and evaluation. This information may include: Upward Bound staff conducting classroom observations, reviewing IEP/504 documents and attending parent/teacher conferences.
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 Catonsville Upward Program during program activities.

This consent hereby releases the CCBC Upward Bound Catonsville Program, its program personnel, Community College of Baltimore County, the Catonsville 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.

The CCBC Upward Bound Catonsville 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.

The participant will abide by the rules and regulations of the CCBC Upward Bound Catonsville 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 Upward Bound Catonsville personnel, perform at a minimum grade level as defined (2.5 cumulative GPA), 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 Upward Bound Catonsville 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 Upward Bound Catonsville 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 Upward Bound Catonsville Program staff as soon as possible.

As part of the application process, please type the email address of your current/recent school counselor AND a current/recent teacher. They will be emailed a recommendation form to complete.