Please let any barriers that would prevent you or challenge your participation in Upward Bound:

EMERGENCY CONTACT INFORMATION – MUST BE PERSON OTHER THAN PARENT/GUARDIAN.

Student should select Agree or Do not Agree for each of the below statements.

Program Participation
I pledge to put forth my very best effort to learn and achieve. I will strive to be present for all program activities during the Academic Year and will participate in the Summer Academy. Activities include, but are not limited to Student Seminars, Student Meetings/Seminars, College Goal Saturday, Educational Field Trips, College Tours, 6 Week Summer Academy, Conferences, Grade Meetings.

• I acknowledge I will be placed on a 90 day probation period after in which academic and participation will be reviewed for full admittance.
• I agree to maintain a 2.5 GPA, if my GPA falls below a 2.5 I will be required to attend tutoring.
• If my attendance falls below 70% a UB staff member will contact student and parent/guardian regarding eligibility status.
• If I have difficulty attending the program, I will notify a UB staff member immediately.
• I will adhere to program dress code during UB activities/events.
• I will adhere to the program and school rules. If I do not, I may be dismissed from the program.
• I understand that failure to follow the rules of conduct, participation and program standards may result in a loss of membership. Upon high school graduation and/or program departure, I give UB staff permission to access & receive any information related to post-secondary progression, including, but not limited to National Student Clearinghouse Student-Tracker Data, academic progress, and any financial aid received towards post-secondary completion.

Code of Conduct
I will model appropriate behavior when participating in the Upward Bound Program. I further understand that I remain primarily responsible for my safety and conduct while participating in program activities. I also understand that my cooperation with the Upward Bound staff, including participation in UB Parental activities is essential to my continuation in the Program and overall academic and post-secondary success. Failure to obey behavior guidelines will result in loss of program membership.

Stipends
Students have an opportunity to earn stipends for academic achievement and participation. I understand I am not entitled to the stipends and I must earn them. Funding is contingent upon the availability of special funds through the Department of Education.

Transportation
Students may receive bus tickets for the purpose of participating in program activities. Students must request a bus ticket 24-48 hours in advance. Students will only receive one bus ticket and one transfer ticket. Bus tickets are distributed at the discretion of the UB staff.

Field Trip Permission
Students will be taking field trips and will have the opportunity to explore many different aspects of Detroit, surrounding cities and postsecondary institutes, etc. Students will be supervised at all times by Upward Bound staff. UB staff members will have cell phone and emergency contact information with them at all times. I give permission for my child to go on field trips. I release CMU TRIO Upward Bound and individuals from liability in case of accident during activities, as long as normal safety procedures have been taken. I have read the above statement. I understand and consent for my student to take field trips during participation in the CMU TRIO Upward Bound Program.

Media Release
I give my consent to CMU TRIO Upward Bound to use my name, photograph, portrait, and any likeness to any media form and type of publication. CMU Upward Bound will provide minimum identifying information and will not use street or mailing addresses, e-mail addresses, or phone numbers. I acknowledge that I have carefully read the Media Release Form and fully understand that it is a waiver and release of liability and that the release of my child’s name/photograph/portrait and any likeness is for the purpose of the CMU Upward Bound Program and is voluntary.

A. Disciplinary Action will be taken against students for:

1. Misbehaving, fighting, disrupting the class, or bothering fellow students.
2. Abusing and/or not taking proper care of CMU TRIO Upward Bound equipment or property.
3. Not listening to UB Staff and not following instructions.
4. As necessary.

B. Procedures for disciplinary action:

1. First Offense
   
   1. There will be one verbal warning to the student.
   2. If the student continues the same behavior, they will be asked to sit out the class/activity.
   3. The student will only be allowed back into class/activity when they ask to return, and the problem has been found and is recognized, acknowledged and resolved.
2. Second Offense
   1. UB staff will contact parent.
3. Third Offense
   
   1. Student will be dismissed from the program and will not be allowed to return to the program until a meeting is held with the UB Director/Staff, student and parent before the student is allowed to participate in future program activities.

C. Offenses calling for immediate dismissal from the Upward Bound program:

1. Possession of any weapons or dangerous instrument.
2. Physical assaults or any act that shows substantial threat to harm or endanger the safety of others.
3. Possession or consumption of alcoholic beverages or drugs.

If a student is dismissed from the program, the Parents/Guardian will be responsible for picking up their student from the event/program.

I hereby certify that the above information about my student is correct to the best of my knowledge and I understand this information is required for my student to participate in field trips with the CMU TRIO Upward Bound Program. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. I also authorize CMU TRIO Upward Bound Staff to administer medication listed above at the indicated dosage and time as needed during field trips.

The following information exchange is being requested from Detroit Public Community School District and Voyager Preparatory High School, in order to facilitate coordinated program services. All information obtained by the agency and/or generated during the course of service is kept confidential and is not open to public inspection.

Mail To:
CMU-TRIO Upward Bound
900 Tower Drive, Suite 100
Troy, MI 48098

I hereby authorize CMU Upward Bound to obtain confidential academic information concerning the above named student and the school to release this information. I also authorize Upward Bound staff to visit my child at school for the purpose of gaining information (educational/program).

I understand that my consent for the release of records is voluntary and I can withdraw my consent at any time in writing. Should I withdraw my consent, it does not apply to information that has already been provided under the prior consent for release.

Sign here only if you DO NOT give consent

ONLY Complete Federal Income Chart verification below, if you MEET the income guidelines for TRIO Programs

Federal TRIO Programs 2023 Annual Low Income Levels are established by the US Census Bureau based on taxable income within 150% of the poverty level. The information below is taken from the U.S. Department of Education’s Federal TRIO Programs Annual Low Income Levels. Effective 1/19/2023 until further notice.

*Box checked below MUST match the number of family members in the household.

ONLY Complete income verification below, if you DO NOT meet the income guidelines for TRIO Programs above

If you filed a 1040 (1040, 1040EZ, 1040 A) income tax form:

I verify that my total annual household income is accurate as recorded above. I understand that falsification of this information constitutes a federal violation and may cause immediate ineligibility and/or termination of membership in the Upward Bound Program. If my child is accepted, I agree to support his/her participation in both the Academic Year and Summer Academy. I will model appropriate behavior when in the presence of students. I further understand that I remain primarily responsible for his/her safety and conduct while he/she is participating in program activities. I also understand that my cooperation with the UB staff, including participation in UB Parental activities is essential to my son/daughter’s admission and continuation in the Program.