CONTACT INFORMATION (list two adults other than your parents whom we can contact):

I attest to the fact that the above information is true to the best of my knowledge.

I understand that the purpose of the Upward Bound Program is to prepare its participants to successfully graduate high school and enroll in post-secondary education. As part of my personal effort in this preparation, I commit to Upward Bound through completion and participation in all academic year and summer components.

I understand that attendance is an integral part of being a participant. Therefore, I agree to attend and actively participate in all classes, meetings and activities sponsored by Upward Bound. I will comply with all rules and regulations of the Upward Bound Program, and I am aware that failure to comply could result in dismissal from the program.

I understand and I am willing to commit to meeting these expectations.

Parent and Student Permission to Release High School and College Academic Information
(You have our consent to release grades, records and test scores to the Upward Bound Program)

FATHER/GUARDIAN

MOTHER/GUARDIAN

LOW INCOME ELIGIBILITY VERIFICATION (all information is kept confidential!)

Follow the link below to determine if you are low-income:

Low-Income Guidelines 

https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html

Income information: (Please check and fill in the total household income)

I certify that all of the above income information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds and any misrepresentation may make the applicant ineligible for participation.

I understand the purpose of the Upward Bound Program is to prepare participants to successfully complete a program of post-secondary education, and would like to have my child participate. Parent involvement and support are major contributing factors to student success, I agree to be involved in the following ways: 1) keep informed of my child’s progress in school, 2) encourage my child to attend all Upward Bound activities, 3) allow my child to attend Upward Bound field trips, 4) participate in Upward Bound events in which parents are invited, 5) share concerns about my child’s education with Upward Bound staff, 6) support the Upward Bound staff in their efforts on behalf of my child. I support the mission of the Upward Bound Program and will make it a priority to assist my child in his/her education.

I hereby attest that all information in this application is true and correct. I also understand that a false statement or misrepresentation will make the applicant ineligible for the Upward Bound Program.

Please list any and all physical conditions that your child may have which might affect his/her participation in this program, and which the Upward Bound staff should know.

Medical Release

I hereby grant permission to the Director of Upward Bound, or authorized representative to furnish first aid as my child (named above) may require, as well as to seek medical attention through the nearest medical facilities such as those provided on campus and those provided medical facilities available when students are on field trips and other authorized activities.
This permission is conditioned upon the understanding that, in an event of serious illness or a need for hospitalization and/or major surgery, the Director will use all reasonable efforts to contact me. Failure in such effort, however, should not prevent the director from providing such an emergency treatment as may be necessary for the best interest of the life of my child.

I give my permission for the above named child to attend Mt. San Jacinto College Upward Bound Program. I am aware that my child will have an opportunity to be chosen to take supervised field trips as part of their participation in the Program. All of the planned activities are culturally or academically relevant and are part of the Upward Bound Program. Parents will receive written information and notice for each trip sponsored by Upward Bound.

EMERGENCY CONTACT

My child has my permission to travel on planned field trips with Mt. San Jacinto College Upward Bound Program staff. In an emergency, if neither of the above named cannot be contacted or time is of essence, I authorize the staff to act in the best possible interest for my child.

In consideration of the engagement as a model of the minor named below, I hereby grant Mt. San Jacinto College (MSJC) and Facebook Upward Bound website (http://www.facebook.com) and all other social media, its legal representatives and assignees, those for whom MSJC is acting, and those acting with MSJC’s authority and permission, the absolute right and permission to copyright and use, re-use and publish, and republish photographic portraits, pictures or video of the minor may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations from time to time, in conjunction with the minor’s own or a fictitious name, or reproductions thereof in color or otherwise make through any media at MSJC’s studios or elsewhere for art, advertising, trade or any other educational related purpose whatsoever.
I also consent to the use of any printed matter in conjunction therewith.
I hereby release, discharge and agree to hold harmless Mt. San Jacinto College, its legal representative or assignees, and all persons acting under its permission or authority or those for whom it is acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof.
I hereby warrant that I am of full age and have every right to contract for the minor in the above regard. I state further that I have read the above authorization, release and agreement, prior to its execution, and that I am fully familiar with the contents thereof.