University Of Tennessee-Knoxville-Pre College-UB-Release Form

The University of Tennessee TRiO / Pre-College Upward Bound
- Note: This information will help the Pre-College Upward Bound Educational Specialist to advise program participation eligibility for financial aid (scholarships, loans, and grants) as well as to determine the applicant's eligibility. Please answer all questions.
  
  All answers will be kept strictly confidential.
- Applicant / Student:
  
  First NameMiddle NameLast Name
- Email:
  example@example.com
- Applicant lives with:
  
  Other
- Name of Head of Household:
  
  First NameMILast Name
- Relationship to Applicant:
  
  Other
- Address of Head of Household:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Does applicant (student) have a job:
- If yes, please list employer:
- How many people are in your household? (Fill in blanks with numbers. If none, write "0.")
  
  Applicant / Student: 1
- Parent(s) / Guardian(s):
- Siblings:
- Other Dependents:
- TOTAL:
- Please specify "other dependents:"
- Please indicate tax return filing status of Head of Household (check one):
- INCOME:
- (1) Adjusted gross income for the last tax year was: $
  (if filing jointly, please include both incomes)
- Do not include income from any of the categories below:
- Social Security:
  $ Monthly amount
- TANF/SNAP:
  $ Monthly amount
- SSI:
  $ Monthly amount
- Unemployment:
  $ Monthly amount
- Disability:
  $ Monthly amount
- Retirement:
  $ Monthly amount
- Additional comments concerning your financial situation:
- I certify that the above information (including income data) is correct to the best of my knowledge. I also understand that all information on this form will be held in the strictest of confidence.
- Head of Household Signature:
- Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- This form needs to be filled out and signed by both, student and parent / guardian.
- Pre-College Upward Bound
  
  As required by the U.S. Department of Education, the grant funding source, participants' success is tracked throughout their academic careers. By signing below, you confirm you and your student's commitment to the program should he or she be accepted.
- Student's Full Name:
  
  First NameLast Name
- Parent's Full Name:
  
  First NameLast Name
- School Name:
- We, {studentsFull} and {parentsFull}, hereby give our permission for {schoolName} to release all needed educational records, including transcripts, period grades, ACT, PSAT, and other standardized test scores, etc., to the Pre-College Upward Bound program for application to the program, and as requested from this point forward.
  
  We also hereby give our permission for information regarding future enrollment, college financial aid packages, and future transcripts of all college-level work to be released to Pre-College Upward Bound Program, 1914 Andy Holt Avenue, 25 HPER Building, Knoxville, TN, 37996.
- Student's Social Security Number:
  999-99-9999
- Student's Signature:
- Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Parent’s or Guardian’s Signature:
- Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Transportation Permission Slip & Liability Release Form
  
  Your child will be participating with the Pre-College Upward Bound program at The University of Tennessee. During some Saturday sessions, as well as during many activities of the Summer Academy (summer camp), it will be necessary for PCUB staff, UT staff, and UT contracted bus companies to transport your child to various locations. By signing this Permission Slip & Liability Release Form, you are allowing your child to travel with the PCUB program and releasing the University of Tennessee and the Pre-College Upward Bound from liability in the case of an accident.
- Student Name:
  
  First NameLast Name
- Additional Comments:
- Student's Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Parent's Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy

The University of Tennessee TRiO / Pre-College Upward Bound