I {parentguardianName} understand that if {studentName} is accepted, participation in the program is a privilege and that rules and regulations of the program must be adhered to on all occasions related to program activities or my child/I may be dismissed. I also confirm that the information contained in this application is true to the best of my knowledge. Specifically, I confirm that the citizenship, academic, financial, and other eligibility information provided is accurate. I understand that I may be asked to provide supporting documentation. I have read information about the program and fully understand the goals of the program which, in sum, are school retention, school graduation, college enrollment the fall after high school graduation, and college graduation. I understand that should the information contained herein is found to be false, my child/I may be dismissed from the program. Participation in the program is not a promise of admission to any of the University of Illinois campuses.

Consent to Release School Records for Limited Purposes: I understand that application and other data (e.g., grades, test scores, graduation, college choices, courses, income) are being requested, maintained, and used for eligibility, needs assessment, service delivery, and research and reporting purposes to show general profiles and effectiveness of program. At no time will my child’s name or my name be identified or linked to published data results without my written permission. I also understand that my child/I may withdraw from participating in any data collection activities without penalty, interuption, or denial of services.

The purpose of this form is for parents to give their expressed consent to their child’s current or last-attended schools to release educational records including: academic transcripts, discipline record, enrollment status, evidence of income, free or reduced lunch status, graduation date, latest report card, standardized test scores, and other educational records that will be used to determine eligibility and
need for services; to understand, monitor, and track academic performance; to monitor and track enrollment status; to assess potential for postsecondary education; and to assess effectiveness of intervention services. All records provided to the program will be confidential, reviewed by program personnel only and auditors assessing compliance and accountability with federal and institutional regulations, and maintained in a secure location at the University of Illinois at Urbana-Champaign.

Needs Assessment: I/my child needs tutoring in Math, Science, and/or English. I/my child also needs other college prep services such as academic advising, exposure to postsecondary opportunities, financial literacy, test-taking strategies, cultural opportunities, and career development. I understand that the purpose of this statement is to assess need for program services.

Permission to Use Images (Please answer yes or no at the end of the statement below): I authorize the program to interview my child/me and to use my child’s image/my image for promotional material, such as advertising, publications, websites, schedules, catalogs, reports, recruiting presentations, view books, radio, T.V., and other methods of communication not stated herein. My child/I may elect to withdraw this permission at any time without penalty, interruption, or denial of services.