Disclosure of your Social Security Number is required of you in order for Texas State Technical College Upward Bound Program to track and report to the U.S. Dept. of Education, as mandated by Federal Law. Further disclosure of your SSN is governed by the Public Information Act (Chapter 552 of the Texas Government Code) and other applicable law.

Information relating to your ethnic background is requested for requirements for state and federal reporting.  The data requested will be used only for the required reports to this agency and will not be used in any way in the admission process.

(To be Completed by Student)

Needs Assessment:

Parent Information

Notice: All information of one parent must be completed in order to be considered a participant for the program.

Household Income Information

We are required by the United States Department of Education to obtain family income verification for all participants served by the TRIO Upward Bound Program.  All information will be held in strict confidence and will adhere to the Family Rights & Privacy Act.

Please indicate the amount received (if any) of the following benefits:

CERTIFICATION INFORMATION:

I certify that the information provided is true & correct to the best of my knowledge. 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 & strictly confidential.

Equal Opportunity shall be afforded within the Texas State Technical College System (TSTC) to all employees and applicants for admission or employment regardless of race, color, gender, religion, national origin, age or disability. TSTC complies with the Texas Equal Opportunity Plan.

SERVICES: My son/daughter, _{studentPrint}_, and I are being asked to participate in the Upward Bound (UB).  Our participation in this program is entirely voluntary and we may refuse to participate, or may decide to cease participation at any time.  Should we decide to withdraw or refuse to participate in the program, our decision will involve no penalty but will result in loss of services to which we are otherwise entitled.  We are also aware that no financial compensation will be offered for participation in the Program. We have been told that the UB staff has the right to withdraw us from the program at any time.  The Upward Bound staff has offered to answer all our questions if we have additional questions or comments during our tenure in the UB program, we may contact Melinda Ortiz, Director of Upward Bound Program at 956-364-4580.  My signature below acknowledges our voluntary participation in Upward Bound. 

We are aware that the purpose of the Upward Bound is to provide educational outreach to students within San Benito Consolidated Independent School District, Harlingen Consolidated Independent School District.  The objectives of the Upward Bound Program are: 1) to identify qualified participants with potential for education at the post-secondary level, 2) to encourage and assist them to continue in and graduate from high school, and 3) ultimately enroll them in a post-secondary program.  We are aware that all students will be recommended to tutoring in areas of academic weaknesses, and receive peer mentoring, career and educational guidance (i.e. admissions, financial aid applications and introduction to different career options) as well as field trips to Texas universities and cultural enrichment.

We are aware that the total anticipated time span for each student involved in the UB Program will last from the time the student enters the program until his/her high school graduation.  Student will be tracked during their post-secondary enrollment to verify completion and comply with survey criteria for the Department of Education.  We are also aware that our participation in all activities is of great importance.  If my child’s participation does not meet the standards of the Upward Bound Program, we are aware that we may become exited from the program and may no longer be permitted to participate in the program’s activities.  

Every effort will be made to maintain the confidentiality of my child’s records.  In no way will my child’s records be revealed. We have been advised that the data collected from the program will be used for educational purposes.  The identity of all the students will be kept in a secure location available only to the Texas State Technical College Upward Bound Staff.

Participation & Field Trip Liability Waiver

As the parent and/or legal guardian of the student listed above, I authorize and permit my child to participate in any and all academic year component activities (classes, tutorials, workshops, field trips, work study internship, meeting and events, etc.) sponsored and/or conducted by the Upward Bound (UB) Program of Texas State Technical College Harlingen. I also give permission for my child to be transported between his/her high school, Texas State Technical College Harlingen, and the scheduled events when the UB Program has scheduled events for its participants. I acknowledge the nature of such activities or trips may expose my child to hazards or risks that may result in his or her illness, personal injury or death, and I understand the nature of such hazards and risks.

In consideration of my child being permitted to participate in the activity or trip, I hereby accept all risk to his/her health and of his/her injury or death that may result from such participation, and I hereby release Texas State Technical College Harlingen, its governing board, officers, employees and representatives from any and all liability to my child, his/her personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss or damage to my child's property and for any and all illness or injury to his/her person, including his/her death, that may result from or occur during his/her participationin the activity or trip, whether caused by negligence of Texas State Technical College Harlingen, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless Texas State Technical College Harlingen, its governing board, officers, employees, and representatives form liability for the injury or death of any person(s) and damage to property that may result from my child's negligent or intentional act or omission while participating in a Project activity or event.

I have carefully read this agreement and understand it to be a release of all claims and causes of action for my child's injury or death or damage to his/her property that occurs while participating in UB Program activities or trips and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my child's negligent or intentional act or omission.

 

My signature on this document indicates that Upward Bound has my authorization to:

1. Grant San Benito & Harlingen Consolidated Independent School District and/or my child’s corresponding school, permission to release any/all, but not limited to:  grades, transcripts, test reports and other academic information requested by the personnel of the Upward Bound Program from 8th to 12th grade.

2. Obtain release of confidential information from 8th-12th grade, (i.e. financial, medical, welfare status, tests, academic school grades, transcripts and questionnaires for project evaluation purposes).

3. Make referrals to other agencies for specific services, (i.e. health, public assistance and psychological or career assessment).

4. Grant post-secondary institutions and National Student Clearinghouse permission to release my child’s college, academic and enrollment information, testing, financial aids awards and scholarships at the chosen college attended after high school graduation.  Please note social security number might be used to obtain this data.  This form will serve as the records release form valid from the date signed until completion of the student’s post-secondary program of study. This information will only be used for reporting purposes for the Department of Education.

5. Transport my child to college visitations, Saturday sessions, summer program activities, various field trips and other Upward Bound events or activities.

6. Access networked computer services such as the Internet, World Wide Web, and electronic mail.

7. Photograph or videotape my child during Upward Bound events for the purpose of publication (i.e.: news release, televised reports, or newsletter) in order to promote and enhance program activities.

8. Provide medical or surgical treatment from an available Hospital or by any Medical personnel in the event of an illness, accident or emergency. 

I understand  {studentPrint74} records will be used to assess student needs, monitor student progress, document eligibility for the program and for additional reporting purposes as needed.

Alternate contacts in case of an emergency if parents/guardian not found:

Medical Release Statement

As the parent/guardian of the above named studetn, I hereby authorize the Director and his/her authorized staff to furnish medical diagnostic and/or authorize the medical and/or surgical treatment of my child as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the child. Texas State Technical College Harlingen and its officers, regents, and employees shall not be liable in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise out of such diagnosis, treatment or surgery to the extent allowed by law, except as procided for through the group medical insurance plan if the student contracted for the same prior diagnosis, treatment, or surgery. Furthermore, TSTC does not assume any financial or other responsibility, but wishes to provide the best services possible in case of emergency.

In case of sudden illness or accident, I consent to emergency treatment by the professional medical/nursing staff of the Student Health Services to my child.  In case of serious illness/accident I will be notified immediately, but if I cannot be reached, necessary interim emergency care may be procided by the Student Health Services professional Medical/Nursing staff or by a physician/nurse designated by them.