Elizabeth City State University-UB-2022 Application Form

ELIZABETH CITY STATE UNIVERSITY

APPLICATION

APPLICATION
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*
(999)999-9999
Birthdate:*

MonthDayYear
Date
Age:*
Are you a United States citizen?*

YesNo
Race: (Check All That Apply)*

Native AmericanAsian/Pacific IslanderAfrican AmericanHispanicNative HawaiianMore than one RaceCaucasian
Are you a disconnected youth? (This means you are living separately from your biological parent(s)—either because of adoption or foster care) *Please note that documentation may need to be submitted.*

YesNo
Sex:*

MaleFemale
What is your preferred first language*

EnglishSpanishOther
Social Security Number:*
999-99-9999
Student Email Address:*
example@example.com
Student Cellphone Number:*
(999)999-9999
Number in Household (Including Yourself):*

List below:

	Name	Relationship	Age
1.
2.
3.
4.
5.

School Currently Attending*
Grade*
School Counselor's Name*

First NameLast Name
List the courses you are taking*
Attach a copy of your current grades to the completed application. *

Cancelof
Have you ever participated in a pre-college program similar to Upward Bound (for example, Talent Search, Gear Up, AVID)?*

YesNo
If yes, please specify program and sponsoring school or organization.
Program Contact Person

First NameLast Name
Phone Number
(999)999-9999

STUDENT QUESTIONAIRE
What are your plans after high school graduation? (Consider listing your goals)*
Why is education important to you? *
What difficulties are you having at this time? (For example, issues with course content, need tutoring in math, english, science, etc..). *
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

PARENT INFORMATION

	Name	Relationship	High School Diploma or GED	2 Year College Degree	4 Year College Degree
Mother
Father
Legal Guardian 1
Legal Guardian 2

Is either parent/guardian an active member of the military?*

YesNo
If you checked yes, write the individual’s Name

First NameLast Name
If you checked yes, write the individual’s Branch
Is either parent/guardian a retired member of the military?*

YesNo
If you checked yes, write the individual’s Name

First NameLast Name
If you checked yes, write the individual’s Branch

PARENT/GUARDIAN STATEMENT OF INCOME
The United States Department of Education requires that the Upward Bound Program staff gather this data in order to determine student eligibility. Failure to provide the necessary supporting documents will prohibit your child from being considered for admission. The personal information you provide to the Upward Bound Program will be kept confidential and is protected by the Privacy Act.
Annual Income Reported on Recent IRS Filing: *
(if you were not required to file because you received benefits listed below, write in a “0”).
The following can be accepted as income documentation:

645.4—

(i) A signed statement from the student's parent or legal guardian regarding family income (must list the yearly taxable income received, must be signed and dated);

(ii) Verification of family income from another governmental source;

(iii) A signed financial aid application; or

(iv) A signed United States or Puerto Rican income tax return.
You will need to submit a copy of your filed 1040, pages 1 and 2. *

Cancelof
Additional Questions:
Does your family receive non-taxable benefits?*

YesNo
Social Security Benefits:*

YesNo
Work First Cash Assistance:*

YesNo
Veteran’s Benefits:*

YesNo
Other (Specify)*
Amount of Monthly Payment from sources listed above, if you checked “Yes.” *
You will need to submit a copy of your monthly statement to document the monthly income received. *

Cancelof
Signature of Parent/Guardian:*

Clear
Date*

MonthDayYear
mm-dd-yyyy

PARENTAL CONSENT FOR ACTIVITY PARTICIPATION
PARENTAL CONSENT FOR ACTIVITY PARTICIPATION

UNCONDITIONAL AND FULL GENERAL RELEASE & COVENANT NOT TO SUE

This is to be read and signed by all participants using Elizabeth City State University (the “University”) facilities and/or participating in any program on the Elizabeth City State University sponsored program (the Upward Bound Program) and their parent/guardian. PLEASE READ THIS CAREFULLY. IT AFFECTS CERTAIN RIGHTS YOU OR YOUR CHILD MAY HAVE IF YOU OR YOUR CHILD ARE INJURED OR OTHERWISE SUFFER DAMAGES PARTICIPATING IN THE PROGRAM. In return for Elizabeth City State University allowing me/my child to participate in the Upward Bound Program and other good and valuable consideration, I agree, and state, on behalf of myself, my child, my heirs, assigns, executors and others, as follows:
1. This Release and Covenant Not to Sue contains the entire agreement between the University and myself/my child and supersedes any previous communications and/or agreement whether verbal or written, with respect to the subject matter of this Agreement.
2. I am competent to read and sign this "Unconditional and Full General Release and Covenant Not To Sue."
3. That I/my child understand/s that I/my child am/are participating in the Upward Bound Program voluntarily and the Upward Bound Program is not required by the University. I/My child understand that participation in the Upward Bound Program is a privilege and that this privilege is a tangible benefit.
4. That I/my child am/are familiar with and will obey, any and all of the policies established by the University located at https://www.ecsu.edu/administration/legal/policymanual/index.html.
5. That I/my child understand/s and appreciate/s the inherent risks and dangers of participating in the Upward Bound Program (e.g., any program physical or other activities) which could result in property damage and/or personal injury (e.g., sprains, broken bones, bruises, sunburn, heat-related illness, or other serious injury, etc.), including death; and I/my child agree to accept all risks whether present or future, known or unknown, arising from or as a result of my participation in the Upward Bound Program.
6. That I/my child WILL HOLD HARMLESS AND INDEMNIFY ELIZABETH CITY STATE UNIVERSITY, its officials, administrators, employees, all sponsors, affiliates, and individuals assisting in the Upward Bound Program for any liability and all claims of damages, demands, and actions whatsoever in any manner resulting from my/my child’s participation in the Upward Bound Program.
7. That I/my child agree/s to assume all costs related with my/my child’s participation in the Upward Bound Program, including but not limited to repair/replacement costs for property damage caused by me/my child, or medical expense.
8. That I understand and affirm that I/my child is/are healthy and reasonably fit in order to safely participate in the Upward Bound Program.
9. That in the event that I/my child am/is rendered unable to communicate due to illness, accident, or emergency while participating in the Upward Bound Program, I hereby give permission to a Physician selected by the Program's personnel to hospitalize, secure proper treatment for, and to take whatever medical actions are necessary to treat me/my child.
10. That I/my child have read and understand this "Unconditional and Full General Release and Covenant Not To Sue."

MEDICAL RELEASE
MEDICAL RELEASE

I understand that in the event that I/my child am/is rendered unable to communicate due to illness, accident, or emergency while participating in the Upward Bound Program’s Academic Year and Summer programs and activities, I hereby give permission to a Physician selected by the Program’s personnel to hospitalize, secure proper treatment for, and to take whatever medical actions are necessary to treat me/my child. I assume total responsibility for all costs associated with such medical treatment.

Emergency Contact Information:
PARENT/GUARDIAN OF PARTICIPANT: *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT NUMBERS:
PRIMARY*
(999)999-9999
SECONDARY*
(999)999-9999
EMAIL ADDRESS*
example@example.com
NAME OF INSURANCE COMPANY: *
POLICY NUMBER: *
PLEASE LIST ANY HEALTH CONCERNS OR ALLERGIES: *
PHYSICIAN’S NAME: *

First NameLast Name
PHONE NUMBER*
(999)999-9999
PLEASE LIST ANY MEDICATIONS PERSCRIBED TO YOUR CHILD THAT ARE CURRENTLY BEING TAKEN:*

PHOTOGRAPHIC CONSENT, WAIVER AND RELEASE
PHOTOGRAPHIC CONSENT, WAIVER AND RELEASE

For Consideration received, I/We hereby release and discharge the University from any and all claims and demands arising out of or in connection with the use of my photograph/my child's photograph, name, likeness or voice, including without limitation any and all claims for libel or invasion of privacy. This confirms that I am of full age and have the right to contract in my own name/my child's name. This acknowledges that I have read the foregoing and fully understand the contents thereof. This release shall be binding upon me, my heirs, legal representatives, and assigns.
Participant Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Full Name*

First NameMiddle NameLast Name
Parent/Guardian Signature *

Clear
Date*

MonthDayYear
mm-dd-yyyy
Full Name*

First NameMiddle NameLast Name
ADDITIONAL INFORMATION (Provide any additional information you wish for the program staff to know about your son/daughter): *

INFORMATION RELEASE & AUTHORIZATION STATEMENT
INFORMATION RELEASE

The information requested below will be used to assist us in providing services to your son/daughter. In order to provide the most effective services, we will need to obtain information from several sources, such as middle schools, high schools, colleges, testing agencies, counselors, admission and financial aid officers, social workers, etc. ALL THE INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY RIGHTS AND PRIVACY ACT.

My signature below authorizes the TRiO Upward Bound personnel to:
1. Request a copy of my high school and/or college progress reports, transcripts, test scores and/or documentation of behavior, grade promotion, or graduation.
2. Request a copy of my middle school progress reports, report card, and/or documentation of behavior, grade promotion, retention, matriculation, test history, and transfer records.
3. Request a copy of my financial aid applications and awards from the federal government, state funding agencies, high school counselors, and post-secondary institutions.
4. Request a copy of my test score reports (SAT, ACT, PSAT, PreACT, EOG, EOC, etc..) from all testing agencies or personnel and/or school counselors or school personnel.
5. Communicate with representatives from agencies or postsecondary or secondary institutions on my behalf.
AUTHORIZATION STATEMENT

I hereby authorize TRIO Upward Bound personnel to contact and request information from, as well as supply information to, the above-mentioned parties.
Student Signature:*

Clear
Student ID Number:*
Parent/Guardian’s Signature: *

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent’s PowerSchool Username:
Password:
*Upward Bound personnel will use your log in information to monitor your child’s progress which is needed to align services to ensure their academic success.

ELIZABETH CITY STATE UNIVERSITY