Cuyahoga Community College-UB-Application Form

Upward Bound Program
Application for Admission

Parent/Guardian Information
Parent 1's Name*

First NameLast Name
Guardian's Name (if applicable)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
(999)999-9999
Emergency Number
(999)999-9999
Employer
Have a Bachelor's (4-year) degree*

YesNo
Parent 2's Name

First NameLast Name
Guardian's Name (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
(999)999-9999
Emergency Number
(999)999-9999
Employer
Have a Bachelor's (4-year) degree

YesNo
I attest that the information supplied on this application is true and accurate.
Parent or Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent email*
example@example.com
Parent email
example@example.com

Essay and Career Interests
How do you believe you can benefit from participating in the Upward Bound program?

Career Interests: I am currently interested in the following careers

	Career Name
1
2
3

Academic and Contact Information and Certification Release
I understand that the Cuyahoga Community College Upward Bound Program is required to collect information regarding program participants’ enrollment and academic performance in high school, and enrollment and graduation from a college or university for up to six (6) years following their graduation from high school as well as contact information including but not limited to name, date of birth, and email address (“Contact Information”).

I hereby grant permission to the Tri-C Upward Bound Program to obtain my high school academic information from the Cleveland Metropolitan School District (or my current high school) and Contact Information, share it with other local organizations as it relates to Upward Bound participation, and to obtain confirmation of my enrollment and/or graduation from any post-secondary institution that I may attend for a period of six (6) years following my graduation from high school. I certify that the information contained in this application is true and accurate to the best of my knowledge. I understand that this is an application for a federally funded program and that deliberate misrepresentation of my application information my subject me to prosecution under applicable state and federal laws.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent 1/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent 2/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Upward Bound Program
Cuyahoga Community College Metro Campus Center (MCC ) 0005L
2900 Community College Avenue Cleveland, OH 44115
(216) 987-4958 (phone) (216-987-4941 (fax)

Family Income Form

Federal Trio Programs
2024 Annual Low-Income Levels
(Effective January, 2024)

Size of Family Unit	Income Level
1	$22,590
2	$30,660
3	$38,730
4	$46,800
5	$54,870
6	$62,940
7	$71,010
8	$79,080

For family units with more than eight members, add the following amount for each additional member: $8,070 for the 48 contiguous states.

Size of family unit*
Income level from chart above*
Taxable income*
Do you meet the criteria for low income?

I have read and understand the federal guidelines for “LOW INCOME” listed above. I certify that I DO MEET the criteria for “LOW INCOME” because there are _______ (size of the family unit) members in my family unit and our taxable income does not exceed ___________ (income level from chart above). My taxable income is $_______________.I have read and understand the federal guidelines for “LOW INCOME” listed above. I certify that I DO NOT MEET the criteria for “LOW INCOME” because there are ______ (size of the family unit) members in my family unit and our taxable income exceeds __________ (income level). My taxable income is $__________.
Parent 1/Guardian Signature*

Clear
Parent 2/Guardian Signature

Clear
Name of the Student*

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy

Emergency Medical Authorization
The purpose of the Emergency Medical Authorization form is to enable parents and guardians to authorize the provision of emergency treatment for their children who become ill or injured while under school authority, when the parent(s) or guardians(s) cannot be reached during all activities and team travel related to and associated with the Cuyahoga Community College Upward Bound Program.
Student Name

First NameLast Name
School
Grade
Parent #1/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Number*
(999)999-9999
Emergency Number
(999)999-9999
Parent #2/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Number
(999)999-9999
Emergency Number
(999)999-9999
PART I – TO GRANT CONSENT OF EMERGENCY MEDICAL TREATMENT

In the event reasonable attempts to contact me have been unsuccessful, I hereby give consent for: (1) the administration of any treatment deemed necessary by the physician or dentist below, or in the event the designate preferred practitioner is not available, by another licensed physician or dentist, and (2) the transfer of my child to any hospital reasonably accessible, I hereby give consent for the following medical care providers and local hospital to be contacted:

Medical Care Providers and Hospital Information

	Name	Phone
Doctor
Dentist
Medical Specialist
Local Hospital/Emergency Room

Medical History of my child’s allergies, medications being taken and any physical impairment to which a physician should be alerted
Medical Allergies
Current Medications
Physical Impairments
Authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

TO GRANT CONSENT OF EMERGENCY MEDICAL TREATMENT
Signature of Parent/Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
- OR - PART II – REFUSAL TO CONSENT OF EMERGENCY MEDICAL TREATMENT

I do not give my consent for emergency medical treatment of my child.
In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following actions
Signature of Parent/Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Release from Liability and Hold Harmless Agreement
In consideration of being permitted in all the Upward Bound Program, I, or my parent or legal guardian if I am under the age of eighteen (18), the undersigned, so hereby agree to assume all the risks and responsibilities surrounding my participation in the Upward Bound Program

And further, I do for myself, my heirs and personnel representatives hereby agree to hold harmless, indemnify, and release and forever discharge Cuyahoga Community College District and all its officers, agents and employees from and against any and all liability, loss, damage, costs, claims, and/or causes of action, including but not limited to all bodily injury

IN WITNESS WHEREOF, I have caused this release to be executed on {date108}
Signature of Participant*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Signature of Parent or legal Guardian if Participant is under the age of 18 years)*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Relationship

Field Trip Form
In consideration of being permitted in all the outside school activities sponsored by the Upward Bound Program, I, or my parent or legal guardian if I am under the age of eighteen (18), the undersigned, so hereby agree to assume all the risks and responsibilities surrounding my participation in the Upward Bound Program

This release gives {main_name} permission to participate in all of Upward Bound activities during the school year. I understand that information will be provided announcing upcoming Upward Bound events.

And further, I do for myself, my heirs and personnel representatives hereby agree to hold harmless, indemnify, and release and forever discharge Cuyahoga Community College District and all its officers, agents and employees from and against any and all liability, loss, damage, costs, claims, and/or causes of action, including but not limited to all bodily injuries and property damage arising out of participation in the program mentioned above.

IN WITNESS WHEREOF, I have caused this release to be executed on {date115}
Signature of Participant*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Signature of Parent or legal Guardian if Participant is under the age of 18 years)*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Relationship

Agreement for the Use of Name and Likeness
Grantor Name*

First NameLast Name
Preferred method of contact
Email Address*
example@example.com
Phone Number*
(999)999-9999
For good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I grant irrevocable permission to Cuyahoga Community College District (the “College”) and its trustees, officers, students, vendors, consultants, agents and employees (collectively, the “Affiliates”) to use my name, photograph, video, likeness, voice, statements or biological material (collectively, “Materials”) associated with Event(s) in any and all manner and media throughout the world, in perpetuity. I wave any right that I may have to inspect or approve any such use.

I agree that the Materials may be edited, adapted, expanded, revised, or modified at the sole discretion of the College and its Affiliates. I consent to use of the Materials in connection with publicity, advertising, promotion, publication, and any other purposes. I understand that the College and its Affiliates may use the Materials in any media or format it chooses, whether or not for profit, including without limitation television, radio, print, promotional materials, and Internet.

I warrant and represent that this agreement does not in any way conflict with any existing commitment on my part. I agree that the College is not under any obligation to exercise any of the rights, licenses, and privileges herein granted.

I agree that no aspect of this agreement or participation in the Event(s) makes me an employee of the College.

I agree to release, waive, forever discharge, and covenant not to sue the College and its Affiliates from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that I may have or that may hereafter accrue to me, arising out of or relating to my participation in the Event(s), the College’s or any Affiliate’s exercise of rights granted by this agreement, including without limitation, claims for compensation, defamation, infringement, and invasion of privacy. In addition, I hereby hold harmless and indemnify the College and its Affiliates from any and all liability, claims, actions, suits, losses and costs or related causes of action for damages arising out of or relating to my
participation in the Event(s), the College’s or any Affiliate’s exercise of rights granted by this agreement, including without limitation, claims for compensation, defamation, infringement, and invasion of privacy. I also understand that this agreement binds my heirs, executors, administrators, and assigns, as well as me.

THIS IS A RELEASE OF YOUR RIGHTS. READ CAREFULLY BEFORE SIGNING.
AGREED AND ACCEPTED:
Grantor Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Signature of Parent or Guardian (if Grantor is a minor)*

Clear
Parent or Guardian Name

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy

Article of Agreement
I understand that I have been accepted to participate in the Upward Bound Program and that my participation status will be monitored for 60 days to ensure that:
- I and my parent/guardian meet with the Academic Coordinator and Advisor to design my Individual Academic Plan
- I attend all scheduled academic enrichment sessions per week.
- I attend all scheduled Saturday seminars.
- I contact the office for any reason if you can not attend Upward Bound activities.
- I follow all of the policies and procedures listed in the Student Handbook.
I acknowledge that I must attend a minimum of 80% of all scheduled program activities to be considered a participant. If I do not meet the 80% minimum attendance requirement, I acknowledge that I will not be considered a participant in the program. I further acknowledge that:
- Program staff will meet to determine whether I have met the requirements to participate in the Upward Bound Program within 60 days of the first day of service.
- I will be eligible to receive a stipend after I successfully fulfill the requirements noted above.
We are aware that by signing this agreement, we agree to the above terms and any violation of these terms may result in my termination from the Upward Bound Program. The signatures below indicate that we have read and understand this agreement; and we are willing to take the actions listed in this agreement to achieve positive results.
Student Signature*

Clear
Parent Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy