Partners In Ministry-UB-Application Form

STUDENT APPLICATION 2022-2023

12 Third Street, Laurinburg, NC 28352 ∙ (910)277-3355 ∙Fax (910)277-3358
PIM Upward Bound Application Checklist:
- Application for Admission
- Essay of at least 300 words
- School Records and Photo Release
- Parents Financial Education Statement
- Teacher Recommendation Form
- Counselor Recommendation Form
Attached Documentation:
- Copy of insurance card
Upward Bound is a 100% federally funded year- TRIO program sponsored by the U.S. Department of Education. The grant is designed to generate the skills and motivation necessary to complete a program of secondary education and to enter and succeed in a program of postsecondary education. Partners in Ministry’s TRIO Upward Bound program serves rising 9th through 12th grade students in the Scotland County area.
Please Note: All Applicants must submit a current academic record (transcript, i.e.), along with their essay, letter of recommendations, parent application, and income verification to complete their Upward Bound application. Applications are accepted for review and participants are selected regardless of race, color, national origin, religion, gender or disability (US Department of Education – GEPA Section 427).
UPWARD BOUND PROGRAM ∙ APPLICATIONS FOR ADMISSION 2022-2023

12 Third Street, Laurinburg, NC 28352 ∙ (910)277-3355 ∙Fax (910)277-3358

This application is our initial introduction to you and will be used to determine eligibility for the Upward Bound Program. It is essential that the entire application be completed before it is returned. Incomplete applications will not be considered for admission. Please Print clearly in ink or type. All of the information collected will be held in the strictest of confidence. Admission in the UB Program will be based on eligibility, need, and readiness for the program.
Student Information
Name:*

First NameMILast Name
Parent Cell #:
(999)999-9999
Student Cell #:
(999)999-9999
Email:*
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday:

MonthDayYear
mm-dd-yyyy
Place of Birth:
Please select

MaleFemale
Name of School Attending Now:
Current Grade:
Name of School Attending in Upcoming Semester:
# of Persons in Household:
Current GPA:
If you don't know, type "unknown"
Graduation Date:

MonthDayYear
mm-dd-yyyy
Counselor’s Name:

First NameLast Name
Are you a U.S. Citizen?

YesNo
Permanent Resident of US?

YesNo
Do you want to go to college?

YesNo
Ethnic Background (check all that apply):

African American or BlackWhiteHispanic or LatinAsian/Pacific IslanderNative Hawaiian/ Pacific IslanderAmerican Indian/Alaskan NativeOther
Degree you plan to obtain (check all that apply):

High School DiplomaAssociatesBachelorsMastersDoctoralUndecided
What is the primary language spoken at home?

EnglishSpanishOther
Who do you currently live with?

Father & MotherFather OnlyMother OnlyGuardian
Parent 1/Guardian’s Name:*

First NameLast Name
Please select if not available:*

N/A
Email:*
example@example.com
Cell #:*
(999)999-9999
Parent 2/Guardian’s Name:

First NameLast Name
Please select if not available:

N/A
Email:
example@example.com
Cell #:
(999)999-9999
Does your parent/guardian currently serve in the military?

YesNo
Have either of your parents earned a Bachelor's degree or higher?

YesNo
Have you ever applied, or participated in, an Educational Opportunity Program (i.e. Upward Bound, GEAR UP, etc.)?

YesNo
If yes, please specify:
How did you find out about our program?

School ReferralRecruitmentFriend/Family MemberOther
Will you require any special accommodations or any other limitations?

YesNo
If yes, please explain:
What extracurricular activities are you involved in?
Do you have internet access at home?

YesNo
What is your favorite school subject(s)?
What is your least favorite subject?
What grades do you usually get?
What classes (if any) needed for tutoring?
Do you want to go to college?

YesNoUndecided
What College/University do you plan to attend?
If you aren't sure, type "Undecided"
What kind of career would you like to have?
If you aren't sure, type "Undecided"
What type of degree do you plan to obtain? You may check more than one:

High SchoolVocation or Technical School Certificate4 Year DegreeMaster DegreeUndecided
Do you work or plan to work this school year and/or summer?

YesNo
If yes, when?
Where?
How many Hours?
By signing below, I certify that all information provided above is true and complete to the best of my knowledge. I also affirm that I have a desire to enroll in college after graduating from high school and seek help with understanding how to apply and pay for college.
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Partners In Ministry Upward Bound Personal Essay
Name:*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
School:*
Essay Topic:*
Your personal essay is a part of the selection process. In 300 words or more, write an essay on one of the following topics: a) Describe a successful student and/or how to become a successful student; b) Describe a school experience that has impacted how you feel about school; c) Describe a situation where you have not been successful and what you have learned about the experience; or d) What do you hope to gain from your Upward Bound experience and what would you contribute to the UB Program.
Personal Essay*
Please identify one teacher and one counselor as a recommender for you to enter the program. Provide contact information below for the project to email a Recommendation Form to each person listed.
Full Name:*

First NameLast Name
Email*
example@example.com
Full Name:*

First NameLast Name
Email*
example@example.com
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Partners In Ministry Upward Bound Program Parent Application 2022-2023

Dear Parent/Guardian:

Your child has indicated an interest in the Partners In Ministry Upward Bound Program. Upward Bound is an early intervention pre-college program that helps students prepare for higher education. The Upward Bound Program provides academic support designed for participants to succeed in their preparation for college entrance and ultimately in their pursuit in post-secondary degrees after high school graduation.

What will my child do in UPWARD BOUND?

· Participate in a year-round program - students begin the program during 9th or 10th grade and participate through high school graduation.

· Maintain regular attendance in school, attend planned sessions, meet with the UPWARD BOUND Program Coordinator and/or Advisor, and attend Saturday Sessions during the academic year.

· Attend a six- week summer program designed to simulate a college-going experience to includes a variety of academic coursework in math, science and foreign language; social, career, and enrichment activities; as well as college/university road trips.

· Attend pre-college admission and financial aid workshops; and

· Participate in parent/family activities that encourages education and engagement.

In order to comply with Federal and program regulations, parents/guardians must complete the parent application and return with your child’s additional application forms (e.g. transcripts, recommendation letters, Verification Document List enclosed for your review. All completed applications will be reviewed and eligible applicants will be contacted for an interview with program staff. Please submit your taxable income verification and parent application via email at info@pim-nc.org or fax, or mail to our office at:

Partner’s In Ministry
12 Third Street
Laurinburg, NC 28352
Phone: (910)277-3355 Fax: (910)277-3358

Thank you for your interest in our Upward Bound Program. Please feel free to call our office at 910-277-3355, if you have any questions or need further assistance.

Sincerely,

Dr. Melba McCallum, Executive Director

Partners In Ministry

Enclosures (2)

Parent Application

Income Verification Document List
Income Verification Document List

INSTRUCTIONS FOR PROVIDING VERFICATION OF INCOME

Please provide verification for ONE of the applicable types of income listed below:

If student qualifies for the free or reduced lunch program: provide a copy of the free/reduced lunch verification letter.

If parent(s) or guardian(s) file a Federal 1040 Income Tax form: provide a signed copy of your most recent tax return showing the number of dependents claimed and the taxable income.

If parent(s) or guardian(s) receive public assistance (TANF, AFDC, General Assistance, etc.) provide verification of monthly benefits.

If parent(s) or guardian(s) receive Social Security payments (SSI, Disability, etc.) provide verification of monthly benefits from your local Social Security Office.

Foster Children or Wards of the Court – no income verification is required. Provide a signed letter from foster parent(s) or guardian(s) detailing foster child/ward of the court status. Include caseworker’s name, address, and telephone number.

If you cannot provide any of the above sources of income verification, please contact Partners In Ministry Upward Bound staff at 910-277-3355.
Partners In Ministry Upward Bound School Records and Photo Release

To be completed by Parent/Guardian

Dear School Personnel:

Your child has indicated an interest in Partners In Ministry Upward Bound Program. Upward Bound is an early intervention pre-college program that helps students prepare for higher education. The Upward Bound Program provides academic support designed for participants to succeed in their preparation for college entrance and ultimately in their pursuit in post-secondary degrees after high school graduation.

To successfully apply for the program, your child must submit a copy of their most recent Academic Transcript and EOC/EOG test scores for program admission consideration.
File Upload

Cancelof
Child’s Name:

First NameLast Name
Current School:
Grade Level:
Child’s Social Security Number:
999-99-9999
Child’s Date of Birth

MonthDayYear
mm-dd-yyyy
RELEASE OF SCHOOL RECORDS

I authorize my minor child to participate in this program, and I agree to adhere to all policies and procedures in the student and parent handbook. Further, I authorize Partners In Ministry to access and/or receive copies of my child’s school records including academic transcripts, grade reports, report cards EOG/EOC scores, and any other academic information and test results necessary to complete the program’s application process for academic assessment, program evaluation, review academic progress academic performance and mandatory reporting. For federal reporting purposes, this release is valid for up to six years post signature.
Parent's/Guardian Name

First NameLast Name
Phone Number
(999)999-9999
Parent’s/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
RELEASE AND AUTHORIZATION TO PHOTOGRAPH

As the parent(s)/guardian(s) of {main_name}, I am in agreement with the goals and purposes of the Upward Bound Program. The Upward Bound Program also has my permission to photograph and/or video my child during program activities. I grant permission to the Upward Bound Program, on behalf of Partners and Ministry and its agents or employees, to use photographs taken of my son or daughter for use in publications such as recruiting brochures, newsletters and magazines; and to use the photographs on display boards, in electronic versions of the same publications or on websites or other electronic forms or media; and to offer them for use or distribution in other publications, electronic or otherwise, without notifying me. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
SCHOOL RECORDS SUBMISSION INSTRUCTIONS FOR SCHOOL PERSONNEL

Please forward a copy of the most recent academic transcript and EOC/EOG test scores for the child listed above to Partners In Ministry. Please submit to our office via email, fax, or by mail. Thank you

Partners In Ministry

P.O. Box 1621

Laurinburg, NC 28353

Email:

Phone: 910-277-3355 Fax: 910-277-3358

Partners In Ministry Upward Bound Parent Application

To be completed by Parent/Guardian
Child’s Name:

First NameLast Name
Current School:
Grade Level:
Child’s Social Security Number:
999-99-9999
Child’s Date of Birth

MonthDayYear
mm-dd-yyyy
Mother’s/Guardian’s Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell
(999)999-9999
Email
example@example.com
Highest College Degree Earned:

NoneAssociatesBachelors (or higher)
Father's/Guardian’s Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell
(999)999-9999
Email
example@example.com
Highest College Degree Earned:

NoneAssociatesBachelors (or higher)
Has either parent received a 4-year degree from a college or university?*

YesNo
Does your child participate in the free or reduced lunch program?

YesNo
Is the child or his/her family homeless?

YesNo
What is the total number of people living in the household (including parents/guardians?*
What was the total income taxable income, for the last tax year, from all Parent(s)/Guardian(s) living in the same household with the student?*
$
What were the source(s) of income listed above? (Please list)
I certify that the annual income, source of income, current number in household and other information provided on this form is true and complete to the best of my knowledge.
Parent/Guardian Information
Mother/Guardian Signature:*

Clear
Mother/Guardian Cell #:
(999)999-9999
Father/Guardian Signature:*

Clear
Father/Guardian Cell # :
(999)999-9999
INCOME INFORMATION SUBMISSION INSTRUCTIONS FOR PARENTS

Please attach an approved document from the Income Verification Document List to verify annual income.

RETURN SIGNED APPLICATION TO PROGRAM STAFF BY FAXING TO (910)277-3358, EMAIL TO: INFO@PIM-NC.ORG , MAIL TO: Partners In Ministry P.O Box 1621, Laurinburg, NC 28353 or DELIVER TO: Partners in Ministry, 12 Third Street, Laurinburg, NC 28352
Admission into Partners In Ministry Upward Bound Program is open to those who meet eligibility criteria, regardless of gender, race, national origin, color, age, religion, or disability (USDOE – GEPA Section 427)
Parent(s) Financial & Education Statement 645.5

To be completed by Parent/Guardian

The personal information you give on the Upward Bound application is protected by the Federal Privacy Act. The information is required by the U.S. Department of Education to determine eligibility. Additionally, the Department of Education has authority to gather information on all Upward Bound participants to monitor their progress. No one may see any information unless they work with or for the program or are specifically authorized to see the information.

All questions must be answered.

1. Household Income
Parent 2 or Male Guardian
Full Name:

First NameLast Name
Yearly Income:
$
Source of Income/Employer:
Occupation:
Relationship To Student:
Work Number:
(999)999-9999
Parent 1 or Female Guardian
Full Name:

First NameLast Name
Yearly Income:
$
Source of Income/Employer:
Occupation:
Relationship To Student:
Work Number:
(999)999-9999
2. Total Family Income for Previous Year
$
2. Total Family Income for Previous Year*
3. Number of people supported by this income*
$
4. Other Sources of Income – Please check if you receive any of the following:

WelfareSocial SecurityTANFFood StampDisabilityUnemploymentVeteran’sPension/retirementChild SupportCompensationAlimony
5. Is your child on the free lunch or reduced lunch program at school?
6. Do you or your spouse hold a Bachelor’s degree?*
I certify that the above information is correct to the best of my knowledge.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Participant Health, Medical Release & Emergency Contact

**Please complete all information and sign**
Participant (student) Information:
Name:

First NameLast Name
Age:
Gender:

MaleFemale
Swimming Ability (0 = Never Swam; 10 = Excellent):

012345678910
Health, Medical and Emergency Contact Information
Does the participant have health insurance?

YesNo
Insurance Carrier
Does participant have any serious health issues?

YesNo
Please Explain:
Does participant have any allergies (include food, environmental, medications)?

YesNo
Please Explain:
List reactions (if any):
Is participant taking any medications?

YesNo
Medications:
Additional information about participant’s health, physical limitations or any restrictions:
Emergency Contact 1:

First NameLast Name
Relationship:
Phone:
(999)999-9999
Emergency Contact 2:

First NameLast Name
Relationship:
Phone:
(999)999-9999
Liability Waiver/ Medical Treatment Consent

Upward Bound Program, Partners in Ministry, and the officers, agents, employees, and volunteers (hereinafter referred to as “releasees”) from any and all liability for injuries or death or property damage to me and/or my family members resulting from, arising out of, or in any way connected with my and/or any of my family member’s participation in the Upward Bound Program or use of Partners In Ministry facilities in connection with this/these program(s). I understand that this waiver and release is applicable even through or if the negligent activities of the releasees may have contributed to the injury or death, or property damage suffered by me or any of my family members participating in this/these program(s). I further agree to indemnify and hold harmless the releasees from and against any and all liability, claims, causes of action, and/or losses of any nature or kind (including litigation-related expenses such as attorney and expert witness fees) resulting from participation in this/these program(s) whether caused by any negligent act or omission of the releasees. I further understand that serious accidents may occur in the Upward Bound Program that I am applying for, that participants in this/these program(s) may sustain mortal or serious personal injuries, and/or property damage, as a consequence of their participation in this/these program(s). Knowing the risks of said events, nevertheless, I hereby agree to assume those risks and to release and hold harmless to the fullest extent allowed by law all of those persons mentioned above who through passive or active negligence or carelessness might otherwise be liable to me for damages. It is further understood and agreed that this waiver, release, hold harmless, and indemnification agreement is to be binding on me, any of my participating family members, and all of our heirs, representatives, and assigns. I hereby authorize qualified physicians to render medical treatment or care that they deem necessary for me or my family members in case of illness or accident during such program(s). In the event of injury of a program participant, and if parent/guardian(s) or emergency contacts cannot be reached, emergency services will be contacted to transport the injured to a nearby local hospital.
Student Signature:*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent Signature:*

Clear
Date

MonthDayYear
mm-dd-yyyy
FIELD TRIP/ EXPERIENCE RELEASE FORM

**Please Print All Information**

· Please complete this form in its entirety.

· Complete the student and emergency contact information.

· Review, complete and sign the Field Trip Experience Acknowledgement and Release

· Return this form to the Upward Bound Staff immediately.
Student’s Name:

First NameLast Name
Emergency Contact Person 1:

First NameLast Name
Phone:
(999)999-9999
Emergency Contact Person 2:

First NameLast Name
Phone:
(999)999-9999
Field Experience Acknowledgement and Release:

I hereby grant permission for my son/daughter to participate and attend the Field Trips provided by and for the Upward Bound Program for which he/she is registered. My child also has my permission to participate in swimming activities on field trips, including aquatic amusement park activities. I am in accord with the purposes of and procedures governing the trip. I understand that adequate and appropriate supervision will be provided. I recognize, however, that unanticipated situations and problems can arise on any trip, school-sponsored or otherwise, which situations or problems are not reasonably within the control of the supervising teacher(s) or staff (including volunteers). I further agree to release and hold harmless the Partners In Ministry Upward Bound Program and its releasees, their agents, officers, employees, and volunteers, from any and all liability, claims, suits, demands, judgments, costs, interest and expense (including attorneys’ fees and costs) arising from such activities, including any accident or injury to the student and the costs of medical services. In the event of an injury requiring medical attention, I hereby grant permission to the supervising teacher(s) or staff (including volunteers) to attend to my son/daughter. If the injury warrants further medical attention, I expect every effort will be made to contact me to receive my specific authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission for necessary medical treatment to be given. In addition, I hereby give my permission to the supervising teacher(s) or staff (including volunteers) to take my child to the physician, dentist, or to the hospital if an accident or serious illness occurs on the trip and I cannot be located. In the event that a student must return from the trip independently for reasons of health, accident, failure to conform to rules established by the teacher/staff in charge, etc., the Upward Bound Program is not responsible for and will not pay for the cost of medical care, transportation and other incidental expenses. This permission slip also serves as acknowledgment that the student and parent(s) understand and agree to the guidelines from each teacher/staff.
Student Name:

First NameLast Name
Signature:*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent Name:

First NameLast Name
Signature:*

Clear
Date

MonthDayYear
mm-dd-yyyy
Student Personnel and Academic Performance Contract

To be signed by the Student and Parent/Guardian

The Partners In Ministry Upward Bound Program staff will provide the appropriate learning atmosphere, academic skills counseling, and college guidelines to the students in the program. This, linked with student motivation and effort, will enable the student to improve his/her potential for gaining admission to an appropriate college or university.

I, {studentName}, as an Upward Bound student promise to: attend all classes/tutorial session on time; complete and turn in all assignments given to me by tutors and teachers on time; attend and participate in all required activities and functions of the Upward Bound Program throughout the year, and abide by the rules and regulations of Partners In Ministry.

In addition, I understand that I am to perform at a minimum grade level; maintain my Upward Bound and high school attendance throughout each academic year; conduct myself in accordance with generally recognized codes of behavior; and be enrolled in a college preparatory tract in high school.

Furthermore, I understand that violations of any of the above provisions will result in review of my continued participation in the program as explained in the Upward Bound Student Policies.
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
As the parent(s)/guardian(s) of {studentName}, I am in agreement with the goals and purposes of the Upward Bound Program. I give permission for my son/daughter to attend all program activities and excursions. The Upward Bound Program also have my permission to photograph and/or video my child during program activities. Moreover, I will agree to participate in program activities during academic year and summer program.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
UPWARD BOUND PROGRAM

STUDENT GUIDELINES AND DISCIPLINE GUIDE

To be Signed by the Student and Parent/Guardian

Upward Bound Students are to:

· Participate in the Upward Bound Program on Saturdays from 9 am – 3 pm during the Academic Year and from 9 am – 4 pm on during the 6-week Summer Academy.

· Act appropriately/respectfully throughout Partners In Ministry Campus and off-campus trips/activities.

· Put All technological devices away during instruction and guest presentations.

· Report to class on time. (Act accordingly while in class. Please, no interruptions.)

· Give faculty and staff notice ahead of time, if parents will be calling during class hours.

· Understand that no visitors are allowed in class

Discipline Guide

All discipline incidents will be placed in the student’s file notes.

1. Verbal Warning

2. Teacher Consultation

3. Phone Call Home

4. Counselor Consultation

5. Parent Conference

6. Director/Advisor Review

7. Termination

8. Appeal

I have read and understand the Upward Bound Program’s Student Guidelines and discipline guide.
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
STUDENT PARTICPATION FORM

To be signed by the Student

Dear Student:

Upward Bound is a federally funded program designed assist high school students succeed in their preparation for college entrance and ultimately in their pursuit in post-secondary degrees after high school graduation. Students must meet the program goals and objectives to remain in the program.

The Upward Bound Program requires that each student demonstrate academic/social progress. Students are required to attend academic classes and will be assessed at the beginning and end of each academic year. The results are used to determine the student’s progress and the effectiveness of the program. Students will also participate in various academic and cultural enrichment activities; which may require in-state or out-of-state travel.

If you have any questions concerning the Upward Bound Program, please contact the office at 910-277-3355.

Sincerely,

Upward Bound Staff
Student Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent Participation Form

To be completed by Parent/Guardian

As the parent(s) of {studentName}, I am in agreement with the goals and objectives of the Upward Bound Program to help motivate my son/daughter to complete high school and enroll in a college/university. I understand that participation in the Upward Bound activities is essential in order for the program to successfully help motivate my son/daughter. Therefore, I agree to encourage him/her to:

(Please initial each item)
Attend school regularly and be on time for all classes.*
Study or read at least 30 minutes per day and complete all homework assignments.*
Attend Upward Bound tutorials if his/her grades in English, Math, or Science drops below a grade level of 78.*
Graduate from high school and enroll in the university or college of his/her choice.*
Attend Upward Bound workshops and meet with the Upward Bound Advisor at least twice per semester.*
I am or will be very supportive of my son/daughter’s educational and career goals.*
I also agree to meet with and/or speak with the Upward Bound Advisor at least twice per year to discuss my son/daughter’s progress.*
I will participate in planned parental workshops as scheduled to further support my son/daughter’s career goals.*
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
New Student’s Parent Interview Form

To be completed by Parent or Guardian
Date

MonthDayYear
mm-dd-yyyy
Contact Numbers:
Home:
(999)999-9999
Work:
(999)999-9999
Mobile:
(999)999-9999
Emergency:
(999)999-9999
Please answer the following questions in the space provided.
What plans do you have for your son/daughter to attend college:*
What things are you doing now to prepare your son/daughter to attend college?*
How can we at Upward Bound help you prepare your child for college?*
How is your child’s attitude toward school?*
Is your child on any medication?*
Are there issues at home or school that your child is currently dealing with?*

Other Emergency Contact Information

	Name:	Address:	Relationship:	Mobile/work #s:
1
2
3

I certify that all the information on this application is true, complete, and accurate to the best of my knowledge.
Name

First NameLast Name
Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Official Records – Transcript Request Form

Student Information
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
mm-dd-yyyy
Phone Number:
(999)999-9999
Grade Level
Graduation Date

MonthDayYear
mm-dd-yyyy
Mail: Partners In Ministry P.O. Box 1621 Laurinburg, NC 28353

FAX: 910-277-3358

Email: info@pim-nc.org
Permission to obtain School Records

I, {parentguardianName} give permission to the Partners In Ministry Upward Bound Program to request and receive education records, test scores, transcripts,and other documentation for the above named participant.
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy

STUDENT APPLICATION 2022-2023