Central Alabama Community College-UB-Application Form

Dear Applicant: Thank you for your interest in Upward Bound at Central Alabama
Community College.

Upward Bound is a pre-college educational program funded by the U.S. Department of Education. The goal of Upward Bound is to assist eligible students in their efforts to complete high school and earn a college degree.

If you wish to be considered for any current or future vacancies in our program, you must submit the information listed below. Incomplete applications will not be processed.
- a completed application (read and sign all forms)
- a copy of student's insurance card
- completed recommendation form
- completed written essay form
- a transcript that includes all high school credits attempted (rising 9th graders must provide middle school transcripts)
- income verification- The following items can be used to verify income:
  1. copy of parent's most recent tax return (with child's information)
  2. copy of letter issued by a government agency verifying income amount (TANF, Social Security, SSI, VA, etc)
  3. statement regarding family income-this can only be used if options 1 and 2 cannot be used
If you have any questions regarding our program or the application process, please contact the Upward Bound office 256-378-2005 or 256-378-2006.

Again, thank you for your interest in Upward Bound at Central Alabama Community College. We look forward to reviewing your application.

Sincerely,

Rachael Harmon
Upward Bound Director
Confidentiality and Information Assurance

The personal information requested of you in the Upward Bound Program Application and by the Upward Bound Program staff is a requirement of the U.S. Department of Education and is considered necessary to substantiate your eligibility to participate. The Federal Privacy Act protects this information. No one may view this information, unless they work for the Upward Bound Program, or are otherwise specifically authorized to see the information. The information on The Upward Bound Program application will be used to determine whether students are eligible for the Upward Bound Program.
Upward Bound
Student Eligibility Requirements
1. A student is eligible to participate in Upward Bound if the family meets income requirements and/or if the student is a potential first generation college student, which means neither of parents has received a 4-year degree.
2. The student must have completed the 8th grade but not entered the 12th grade and must be enrolled in one of the following high schools: Childersburg, Winterboro, B.B. Comer, Sylacauga, Vincent, Coosa Central, or Fayetteville.
3. The student must possess an academic need. The following are examples of
  academic needs: needs assistance with study habits, needs assistance with test taking skills, needs tutoring, needs additional content area instruction, etc.
4. The student must have one recommendation from a high school teacher, counselor, or principal.
5. The student must demonstrate and exhibit an interest in preparing for college while in high school and attending college upon graduation. Upward Bound focuses on college tours, cultural/enrichment trips, and academics.
6. The student's high school transcript must reflect a cumulative grade point average not less than a 2.5 ("C" average) at the time of submission of the application. Please read Academic Agreement carefully.
7. The student must be in good standing with his or her high school. The student's
  record must show overall good conduct and behavior.

Confidential Health Record
Students name

First NameLast Name
Birth date

MonthDayYear
mm-dd-yyyy
Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Home Phone Number
(999)999-9999
Parent's/Guardian's Name

First NameLast Name
Person to be notified in emergency, if other than above

First NameLast Name
Day Phone
(999)999-9999
Evening Phone
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Family Doctor

First NameLast Name
Phone of Family Doctor
(999)999-9999
Does your child have any severe medical problems or disabilities, such as asthma, drug allergy, heart disorder, epilepsy, diabetes, etc.?

YesNo
If yes, please specify
Please check if your child has any of the following

AsthmaEpilepsyTuberculosisDiabetesKidney troubleFainting spells
Can your child swim?

YesNo
Has your child had a serious illness, injuries, or surgery in the last three years?

YesNo
If yes, please describe
Is your child now under a doctor's care or taking any prescription medication?

YesNo
If yes, please explain the condition requiring care and the treatnent or medications being used at this time:

Has your child been immunized against the following? Please give most recent date.

	Date
MMR (measles, mumps, rubella)
Tetanus/Diphtheria
Smallpox
Typhoid
Other

School Records Release Form
I, {main_name}, hereby consent to the release of my academic records including but not limited to transcripts, grade reports, test scores, course evaluations, attendance records, recommendations and other information regarding my school Performance to Central Alabama Community College's Upward Bound Program. This release is to be effective throughout my middle school, high school, and college career and includes my final transcripts upon graduation from secondary school and college. It is effective regardless of whether or not I am actively involved with Upward Bound at the time of the records request.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Birth Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Permission

As the parent/guardian of {main_name}, I hereby consent to the release of my child's academic records, including but not limited to transcripts, grade reports, test scores, course evaluations, attendance records, recommendations and other information regarding my child's school performance, to Central Alabama Community College's Upward Bound Program. This release is to be effective throughout his/her middle school, high school, and college career and includes his/her final transcripts upon graduation from secondary school and college. It is effective regardless of whether or not my child is actively involved with Upward Bound at the time of the records request.
Parent/Guardian's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Attendance Agreement
To be a successful Upward Bound student, you must have a willingness to participate in all Upward Bound functions. Upward Bound functions include: Saturday meetings (2 monthly), field trips, cultural activities, tutoring (if necessary), workshops, etc.
The Upward Bound Summer Component is a critical portion of the Upward Bound program. During the summer, students are required to attend Upward Bound for 6 weeks. The Summer Component prepares students for the upcoming school year. The Summer Component is mandatory. Failure to attend will result in dismissal. This is not a residential program.

Extra-Curricular Activities- We understand that students often participate in sports and organizations. We love for our students to be involved in extra-curricular activities. If you choose to participate in sports/organizations, it is your duty to also attend Upward Bound. If you are not present, you cannot benefit from our services.
Please list all of the activities that you participate in on the spaces below.
Jobs- If you choose to get a job, it is also your responsibility to attend Upward Bound. Failure to attend Upward Bound will result in dismissal.

ATTENDANCE POLICY
1. Tardiness will result in a reduction of stipend amount. Excessive tardiness will result in dismissal is your responsibility to sign in. Do not sign in your friends!
2. Students cannot exceed (3) unexcused absences. An unexcused absence results from no show, no call. The 4th unexcused absence will result in dismissal.
3. Students cannot exceed (3) excused absences. An excused absence is given when you call or email. Excused absences can be used for: illness, family vacation, sports, work, etc. The 4th excused absence will result in dismissal.
4. If you play sports, you are still expected to attend Upward Bound. You can check-out early.
5. You must be on time for all field trips.
6. If you are scheduled to meet with a tutor and you do not show, that will count as an unexcused absence. You must call.
7. The following activities will not count against your attendance: taking an ACT test, attending AP classes, college placement testing, high school college tours (not personal tours). The Upward Bound Director must be notified in advance to provide approval.
8. Upward Bound does not provide transportation from your home to the college.
We {main_name} and {parentsguardiansName} enter this agreement with Upward Bound at Central Alabama Community College. We agree to the terms listed above. We have read and understand the terms. Failure to follow the terms will result in dismissal from the program.
Date

MonthDayYear
mm-dd-yyyy

Academic Agreement
The Upward Bound Program is designed to prepare students for college. All students should work hard to ensure his/her academic success.
1. All students must submit grades after each grading period.
2. All students will receive an academic plan. You must follow your academic plan.
3. Upward Bound students should maintain a cumulative GPA of 2.5 ("C" average)
  or better while enrolled in Upward Bound.
4. Students must maintain a good academic standing. Grades cannot drop to a D or F.
5. Students that earn failing grades must meet with the remediation teacher for tutoring.
6. Students must have a desire to attend college.
7. Students must be willing to prepare for college while in high school. The following are required: ACT prep, ACT testing, attending college tours, attending cultural/enrichment trips, completing Bridge application, applying for colleges, completing FASFA, completing a career plan, etc..
8. Students will receive binders on the first day. It is the student's responsibility to take proper care of all materials.
9. You should notify the Upward Bound Director of supplies that are needed for school and Upward Bound. Some supplies should be returned.
We {main_name} and {parentsguardiansName} enter this agreement with Upward Bound at Central Alabama Community College. We agree to the terms listed above, We have read and understand the terms. Failure to follow the terms will result in dismissal from the program.

Minor Student Media Release
I, parent/guardian of {main_name}, a minor student of Central Alabama Community College's Upward Bound Program, do hereby give permission, Central Alabama Community College Upward Bound, to use my child's photograph or photographic image, name, age, honor roll information and voice recordings in official Upward
Bound business, including: Upward Bound web sites, newsletters, newspapers, videos, and other print and electronic materials as deemed appropriate by Central Alabama Community College Upward Bound Staff. It is agreed that the use of any photograph or photographic image of our students shall in no way be used in any other forum other than for official CACC/Upward Bound business.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Emergency Contact Information
If under the age of 19
Parent or Guardian

First NameLast Name
Relation to Student
Home Phone
(999)999-9999
Alternate Number
(999)999-9999
Place of Employment
City
Work Number
(999)999-9999
Emergency Contact #2 (in case the parent/guardian above is unavailable)
Emergency Contact #2

First NameLast Name
Relation to Student
Home Phone
(999)999-9999
Alternate Number
(999)999-9999
Place of Employment
City
Work Number
(999)999-9999
If 19 or older

Next of kin or power of attorney
Name

First NameLast Name
Relation to Student
Home Phone
(999)999-9999
Alternate Number
(999)999-9999
Place of Employment
City
Work Number
(999)999-9999

Student Essay
Student Name

First NameLast Name
Student Essays — Must be completed independently by the student
Write an essay explaining your academic goals and future plans. How will Upward Bound help you meet those goals? In addition, please tell us what you expect to gain from your experience in Upward Bound.

Recommendation Request
Please include the name and email of a teacher to recommend you to the Central Alabama Community College Upward Bound program.
Teacher Name

First NameLast Name
Teacher Email
example@example.com
Confidentiality and Information Assurance

The personal information requested of you in the Upward Bound Program Application and by the Upward Bound Program staff is a requirement of the U.S. Department of Education and is considered necessary to substantiate your eligibility to participate. The Federal Privacy Act protects this information. No one may view this information, unless they work for the Upward Bound Program, or are otherwise specifically authorized to see the information. The information on The Upward Bound Program application will be used to determine whether students are eligible for the Upward Bound Program.