I hereby authorize all officials to release my high school and college transcripts, TCAP scores, Gateway scores, EOC scores, and any other pertinent schools records and test scores to the ETSU Upward Bound program. I understand that Upward Bound will track my post-secondary participation in accordance with grant requirements. I understand and agree that all information furnished in this application is correct to the best of my knowledge and that all information will be kept confidential.
Parental Consent and Release
During the Program, students may participate in dangerous and/or hazardous activities. I expressly assume all risks involved with my Child participating in these activities. Minors may be unsupervised at certain times during the Program. Program activities include attending college preparatory academic classes, attending enrichment/elective activity classes, attending off-campus cultural / educational activities, participating in job shadowing and internship opportunities, living in a residence hall, participating in small group/large group activities and participating in recreational activities.
Release. I agree to release, waive, indemnify, and forever discharge the University, its agents, employees, officers, and trustees from any and all claims or liability for injury or damages (including loss or damage to property) arising from or attributable to my child's participation in or travel associated with the Program, unless it is due to the willful fault or gross negligence on the part of the University.
Photo/Video. I hereby authorize the University and those acting pursuant to its authority to record my child's likeness and voice in any medium; use my child's name in connection with these recordings; and use, reproduce, exhibit, or distribute in any medium these recordings for any purpose that the University deems appropriate, including promotional or advertising efforts.
USDA Non-Discrimination Statement
The ETSU Upward Bound program participates in the USDA (United States Department of Agriculture) Summer Food Service Program. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, DC 20250-9410 or by fax (202) 690-7442 or by email at firstname.lastname@example.org
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (Spanish).
USDA is an equal opportunity provider and employer.
Parent and Student Signature:
I certify that the education and financial information that I am submitting in this application is accurate.
I certify that I agree to the above Information Release, Parental Consent and Release, and USDA NonDiscrimination Statement provided in this application packet.
By signing below, the student agrees to participate in the various Upward Bound activities mentioned in the application packet. Furthermore, the parent/guardian signature below states that you (parent/guardian) support your student participating in the various activities offered by the ETSU Upward Bound program. (If you have any questions about any activities, please do not hesitate to call the office at 423-439-5619.)