STUDENT AUTHORIZATION FOR RELEASE OF ACADEMIC RECORDS AND INFORMATION

I submit this information to be considered as a participant in the Sinclair Community College TRIO Upward Bound program; I certify that the information is true and correct to the best of my knowledge. I release the following information from public school records to the TRIO Upward Bound program: transcripts, test scores, income, and other information necessary for program application completion, provision of academic support, and verification of student progress. All information provided on this form will be kept confidential and will not be disclosed to a third party by the program without my permission. I understand that my parents/guardians will be required to disclose information, such as household income, necessary to determine my eligibility for program participation.

STUDENT/PARENT/GUARDIAN RELEASE AUTHORIZATION

By my signature below:

• I certify that the above information is correct and true to the best of my knowledge.
• I agree that Sinclair Community College, Upward Bound staff, or volunteers associated with the college will not be held liable for any loss, injury, or death related to any field trip, activity, or event.
• I authorize the Upward Bound staff access to any and all academic records/transcripts/social security numbers available from the school the student/applicant attends for the purpose of determining eligibility and providing educational services.
• I authorize and permit my child to participate in field trips, activities, and events sponsored and conducted by Upward Bound.
• I grant permission for my child to access networked computer services such as the Internet, World Wide Web, and electronic mail.
• I grant permission to the Upward Bound program to use images of my child for the purpose of promoting the Upward Bound program and Sinclair Community College.
• In the event that my child is involved in a medical emergency, I authorize Upward Bound staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc.), if I am unable to be contacted or reached for verbal authorization.

Along with completing this application, you must select at least one teacher or counselor to submit a recommendation on your behalf. Enter the teacher or counselor’s name and email below, and the Recommendation Form will be sent to them.

THIS FORM MUST BE COMPLETED IN ITS ENTIRETY.

Purpose: This form enables parents (or a participant age 18 or over) to authorize emergency medical treatment in the event of illness or injury while the child is a participant in any activity or trip with Sinclair Community College and provides health information and medical insurance information about the child.

If yes, please complete the following and provide copy of health insurance card:

If CareSource:

In the event that reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of medical treatment deemed necessary by licensed paramedics, physicians, or dentists and to have my child transported to the closest medical emergency facility accessible. This authorization DOES NOT COVER major surgery unless the medical opinions of two (s) physicians or dentists concurring on the necessity of life-saving surgery are obtained BEFORE the surgery is performed.

If participant is age 18 or over, he or she must also sign below.