SECTION 1: STUDENT INFORMATION

This page to be completed by the STUDENT.

Section 2: Family and Household Information (to be completed by parent/legal guardian)

This section is to be completed by the adult who is legally responsible for the applicant.

If no, with whom does the applicant reside:

Parent 1

Parent 2

*This information is used to determine the student applicant’s first-generation status.  A student is considered first-generation by the following definition: “neither of whose natural or adoptive parents received a baccalaureate degree (4 year degree) or student who, prior to the age of 18, regularly resided with and received support from only one natural parent or adoptive parent and whose supporting parent did not receive a baccalaureate degree (4year degree) at the time of the student’s application.

Legal Guardian (if other than parent)

Section 3: Family and Financial Information (to be completed by the parent/legal guardian)

Please note that all financial information will be kept in the STRICTEST CONFIDENCE and will only be seen by the appropriate Upward Bound personnel to determine the student’s eligibility for the program.

FOSTER CARE NOTE: If student is in foster care or a ward of the state, the parental income does not impact the student’s eligibility to participate in the program.  However, written verification of the student’s status is required from the appropriate agency.  Foster parents may sign the application.

Section 4: Signatures

STUDENT SIGNATURE OF CONFIRMATION AND ASSURANCE

We (student applicant and parent/legal guardian) understand that the Cranbrook Horizons-Upward Bound program is a year-round program with required activities taking place during both the school year and the summer.

I (student applicant) will fully participate in the required activities.  I understand that once I am a participant in the program, HUB will track not only my high school progress but also my post-secondary progress. Even if I am terminated from the program, move out of the area, or can no longer participate, I authorize the Horizons Upward Bound program to access and report my high school and postsecondary progress as required by federal guidelines, throughout my high school and postsecondary career.

I, (student applicant) have read these statements and verify/consent to their content.  I understand that my electronic signature is legally binding and that my electronic signature may not be invalidated solely on the basis that the signature was electronically obtained.

PARENT/LEGAL GUARDIAN SIGNATURE OF CONFIRMATON AND ASSURANCE

I, (parent/legal guardian) have read this application, and verify that the information submitted herewith is complete and accurate to the best of our knowledge.  In signing this application, I give my consent for my son/daughter to participate in the Horizons-Upward Bound program at Cranbrook School if he/she is selected.  I also agree to notify the HUB staff of any changes in home address, personal contact, and/or emergency contact information.  I understand that my electronic signature is legally binding and that my electronic signature may not be invalidated solely on the basis that the signature was electronically obtained.

SECTION 5: STUDENT RECORDS RELEASE FORM

Horizons-Upward Bound
PO Box 801
Bloomfield Hills, MI 48303-0801
Office: 248.645.3593 | Fax: 248.645.3081
huboffice@cranbrook.edu

I acknowledge that the purpose of the Cranbrook Horizons‐Upward Bound program is to prepare me/my child to successfully graduate from high school and a four‐year post‐secondary institution of higher education. As a federally‐funded program, Upward Bound must abide by the U.S. Department of Education’s policies and regulations in regards to tracking current and former Upward Bound students [Authorization: U.S. Department of Education: 34 DFR Part 645.32 (b) (4) and (b) (5)]. As such, I understand Horizons‐Upward Bound’s obligation in obtaining academic documentation from my current or previous high school(s) and six years following the end of my high school graduation and enrollment into a four‐year post‐secondary institution.

I hereby authorize all high‐school and post‐secondary documentation (transcripts/ grades, testing and attendance information) to be released to Cranbrook Horizons‐Upward Bound.

I understand that my electronic signature is legally binding and that my electronic signature may not be invalidated solely on the basis that the signature was electronically obtained.

IEP/504 Plan Release

In order for our staff to work with each HUB participant most effectively, we ask that you give us permission to obtain a copy of any individualized plan created to assist the participant in their academic efforts.