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  • Gadsden State Community College - (Gadsden) - Upward Bound - Application Form

  • TO PARENT (natural or adoptive) OR LEGAL GUARDIAN: The personal information that you give to the Upward Bound Director is sent to the U. S. Department of Education. The information is protected by the Privacy Act. No one may see the information unless they work with or for the Upward Bound Program or are specifically authorized to see it. The information is necessary to determine if your child is eligible to participate in Upward Bound and helps the U. S. Department of Education measure his/her success. The U. S. Department of Education has the authority to gather such information (20 USC 1231a). Your child is not eligible for any services from Upward Bound unless the information is given. Upward Bound is a TRIO program 100% federally funded by the U.S. Department of Education. (Updated 5/3/2021)

     

    In order to be considered for admission in the Gadsden State Community College Upward Bound Program, all forms must be completed and returned. Also, a personal interview with the student will be made by an Upward Bound staff member after all necessary information and documents have been received. Return all parts of the application to your high school counselor or mail them to the Upward Bound office.

    • Part A: Student Information 
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    • Services (Needs Assessment) 
    • Part B: Family Information (TO BE COMPLETED BY PARENT/GUARDIAN) 
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    • Part C: Medical Data 
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    • Health Status of Student

    • Medical Emergency

    • My signature, affixed to this simple document, authorizes the Gadsden State Community College Upward Bound Program to provide medical services of, or advice from a Physician of its choice in case of emergency or illness to my child, if necessary. Follow-up medical care is also authorized, and I will assume all financial responsibility for medical treatment. I hereby release Gadsden State Community College Upward Bound Program of further obligation when above procedure is followed.

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    • Part D. Information Authorization Release 

    • I give permission to Gadsden State Community College Upward Bound to have access to my son’s/daughter’s student rec-ords, such as transcripts, disciplinary reports, report cards and test results, which may be on file in my child’s high school. In addition, I give permission to Upward Bound to exchange such records with other educational institutions. This permission is given with the understanding that such access and exchange of student records will be done in order to enhance my son’s/daughter’s educational opportunity and to assist Upward Bound in evaluating students’ progress.

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    • Part E: Parent’s (natural or adoptive) or Guardian’s Consent 

    • As the parent/guardian, I certify that my son/daughter/ward has my permission to participate in this program for pre-college students. It is my understanding that he/she will register at and be subject to the regulations of the host institution and the program. I authorize the Upward Bound Program/Gadsden State Community College to provide transportation for my child to program activities. I hereby release the Upward Bound Program/Gadsden State Community College from any responsibility for any criminal act of malice, vandalism, theft and any other unlawful behavior during his/her trips sponsored by the Upward Bound Program/Gadsden State Community College.

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    • Participation Agreement 

    • I agree to participate in Gadsden State Community College’s Upward Bound Program and the information provided by me on the previous pages is correct to the best of my knowledge.

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