Please note* These documents are required by federal law. Please turn in COPIES of the following information.

1. Copy of you last report card.
2. Copy of your birth certificate or permanent resident card (if you are from another country).
3. Signed Income Verification Form or written statement that includes annual taxable income and household size. The statement must be signed and dated. (If you did not file taxes, you can complete the Income Verification Form or write a statement stating that you did not file taxes and upload the statement). You may submit a copy of your parent/legal guardian's last income tax filed (form 1040). If you elect to turn in income tax return it must include the first two pages, and the second page must be signed. (i.e. If you are applying in 2024, then you should turn in the 1040 from 2022 or 2023). If you need a copy of the Income Verification Form please email Rosie Flores @ rosario.flores2@hccs.edu
4. Copy of your families Medicaid Care (for the current month) or verification receiving financial assistance from the Texas Department of Human Services. (if you do not receive Medicaid, write a statement stating that you do not receive Medicaid or financial assistance and upload the statement)
5. Copy of Award Letter from Social Security Administration if your parents are receiving assistance from Social Security Administration because of a  as Survivors.

If you have any questions, please call the Upward Bound Program Office

UPWARD BOUND PROGRAM
HOUSTON COMMUNITY COLLEGE- CENTRAL
1300-B Holman St. Suite 107, MC 1229H
Houston, TX 77004
Phone: (713) 718-6388
FAX: (713) 718-6390

I HAVE READ AND UNDERSTAND THE INFORMATION CONTAINED IN THIS APPLICATION. I CERTIFY THAT ALL INFORMATION THAT I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

I, {parentlegalGuardians}, Parent/Legal Guardian of {main_name}, am aware, and agree that Houston Community College System here in after called the college, its agents, officers, employees and assignees are not, nor will they be held personally or officially liable for any and all damages resulting from any and all incidents, accidents, injuries, or claims which may arise out of my child’s participation in the Upward Bound Program. I understand that he/she is participating in this program and its program activities totally at his/her own risk. The college will not, in any circumstances, be held liable for any accidents, incidents, injuries or claims that may arise out of such program activities, including but not limited to field trips, outings, tours, gatherings, and other activity.

I am also aware that this waiver does not excuse the college, for any negligent conduct that directly cause injury to my child.

Wherefore, I waive any and all rights that may arise to hold liable by any cause of action the college, its agents, officers, employees, and assignees in their official or personal capacity.

The FERPA Certification and Release: The Family Educational Rights and Privacy Act or FERPA, was enacted to protect the privacy of student records. I hereby authorize the release of official school records to the Upward Bound program at Houston Community College, furthermore, the release of documents and obtaining of documents relative to and consistent with my education. I understand that these records will only be used in planning educational goals and fulfilling Upward Bound's federal documentation requirements. I certify that the information on this form and any attachments are true, complete, and accurate to the best of my knowledge. I UNDERSTAND THAT THIS INFORMATION WILL REMAIN STRICTLY CONFIDENTIAL

I, the model, hereby grant Houston Community College permission to make still photographs, video tapes, audio recording and/or use of verbal quotes from me. I also give Houston Community College permission to use these completed audiovisual and print products for Houston Community College promotional purposes without compensation or remuneration to me in any manner; in like and related regard, HCC will not charge or assess me any fees or service charges for my voluntary participation in this audiovisual product production.

Further, I relinquish and give to the Houston Community College all rights, title and interest, if any, I may have in the completed video tapes, still photographs or audio recordings, negative, prints, reproductions and copies of the masters, negatives, recordings, duplicates, prints and verbal quotes for print. Witness our hands and concurrence to the above terms:

Parents and students must fully understand the commitment they are making to the Houston Community College – Central Campus Upward Bound Program and the investment the program is making in each participant.

Student Participation Statement:

Our signatures below indicate that we have reviewed the commitment statements and agree to abide by the regulations and policies that govern participation in the HCC – Central Upward Bound Program.

Parent’s/Legal Guardian’s Commitment to TRIO – Upward Bound- HCC-Central Campus

Your son/daughter is starting their academic journey and will need your support. As a parent/legal guardian I know that my child is participating in the Houston Community College - Central Campus - Upward Bound Program. I do hereby commit to the following:

1. I ensure that my son/daughter will attend his/her scheduled high school classes each day.
2. I ensure that my son/daughter will attend all Upward Bound Saturday academic classes and activities; and the 6 weeks Summer Component.
3. I ensure that my son/daughter will participate in tutorials with the Upward Bound instructors/tutors to strengthen skills in areas where tests and grades have revealed a weakness.
4. I ensure that my son/daughter will abide by the Program rules and regulations.
5. I shall provide information such as grades, schedules, and release forms to Upward Bound staff upon request.
6. I shall keep an open line of communication with the Upward Bound staff via email, phone communication, face to face meeting, and texting.
7. I will model a positive behavior with my student.
8. I will attend the three (3) parent meetings per academic year.

Person to be notified in case of an emergency:

IF "Yes", please answer the questions below:

The undersigned parent (or guardian) of, ________________________, whose birth date is ___________, hereby authorizes staff members in the Upward Bound Programs at Houston Community College Central to seek and authorize medical treatment for my son/daughter in the event of an emergency. If an emergency arises requiring a major surgical procedure, the program staff will attempt to reach me to be guided by my wishes; but if I cannot be reached, I authorize the attending physician to proceed as deemed advisable.