271535-Pennsylvania State University-Univ-Altoona-UB-2022 Application Form-Ian

Student Application for Services

Thank you for your interest in Upward Bound Programs! Please complete all sections of this application. Responses for all Items are required.
Si desea ver el formulario en español, cambie el idioma en la esquina superior derecha.

إذا كنت تريد عرض النموذج باللغة العربية ، فقم بتغيير اللغة في الزاوية اليمنى العليا.
- Please complete this application with a parent or guardian.
- Questions? Please contact the Upward Bound Programs office at (814) 865-2320 or by email at upwardbound@psu.edu
Student Contact and Demographic Information
Student Name:*

First NameMILast Name
School:*

Altoona Area High School
Current Grade:*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Social Security Number:*
999-99-9999 (if unknown, enter 0s)
Student Cell Phone Number:
(999)999-9999
Home Phone Number:
(999)999-9999
Birth Date:

MonthDayYear
mm-dd-yyyy
Gender:

MaleFemale
Student Email Address (must be an email you actually use):*
example@example.com
Are you Hispanic/Latinx of any race?

YesNo
Check all that apply:

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
Anticipated High School Graduation Year:
Are you enrolled in any college preparation program similar to Upward Bound?

YesNo
If yes, please provide the name of the program.
List any clubs, activities, or jobs your participate both in and out of school:
List up to three careers that interest you:
1. Career interest:
2. Career interest:
3. Career interest:
All information is required and will be kept strictly confidential and secure. Any incomplete information will delay the process of your request. For more information, call 814-865-2320
BIOLOGICAL / ADOPTIVE PARENT information is required.

*DO NOT INCLUDE stepparent information
Mother's Name:

First NameLast Name
Please choose one of the following points:

This parent lives in the same home as the studentThis parent DOES NOT LIVE in the same home as the student, but provides financial supportThis parent DOES NOT LIVE with the student AND DOES NOT provide financial supportThis parent is deceased
Highest degree earned by mother:

NoneHigh School Diploma/General Education DiplomaAssociate's DegreeTechnical CertificateBachelor's degree
Did mother earn any of these degrees outside the United States?

YesNo
Father's Name:

First NameLast Name
Please choose one of the following points:

This parent lives in the same home as the studentThis parent DOES NOT LIVE in the same home as the student, but provides financial supportThis parent DOES NOT LIVE with the student AND DOES NOT provide financial supportThis parent is deceased
Highest degree earned by father:

NoneHigh School Diploma/General Education DiplomaAssociate's DegreeTechnical CertificateBachelor's degree
Did father earn any of these degrees outside the United States?

YesNo
FOSTER- OR STEP-PARENT / GUARDIAN

Complete only if the student does not live with the biological or adoptive parents.
Foster Parent / Guardian Name:

First NameLast Name
Relationship to student (eg, aunt, uncle, sister, grandfather, adoptive parents):
STUDENT CITIZENSHIP STATUS
Is the student a U.S. citizen?

YesNo
If no, is the student considered a Permanent Resident with a Green Card or VISA?

YesNo
The student is not a US citizen or Permanent Resident, but has applied for citizenship.

YesNo
Student is none of the above.

YesNo
INFORMATION ON HOUSEHOLD AND INCOME
Total Household Family Size Including Applicant and Any Children Away at School:

12345678More than 8
Annual Taxable Income (NOT Adjusted Gross Income) Use your tax return and refer to Line 10 on Form 1040 to find this amount:

$22,590 or less$22,591-$30,659$30,660-$38,729$38,730-$46,799$46,800-$54,869$54,870-$62,939$62,940-$71,009$71,010-$79,079$79,080 or more
Did you file an income tax return last year?

YesNO, because all income was from nontaxable sources (i.e., AFDC, Disability, SSI, Unemployment, Veteran Benefits, Etc.)
By signing below, I testify that all the information provided is correct to the best of my knowledge.
Parent/ Guardian Name:

First NameLast Name
Parent / Guardian Signature:*

Clear
Date Signed:

MonthDayYear
mm-dd-yyyy
Mother/Guardian Telephone #1:
(999)999-9999
Father/Guardian Telephone #2:
(999)999-9999
Mother/Guardian Work Phone Number:
(999)999-9999
Father/Guardian Work Phone Number:
(999)999-9999
Parent / Guardian Email Address:
example@example.com
Student Consent
As a Penn State Upward Bound Programs participant, I understand that I must meet the following requirements:
- Maintain an academic average of 2.5 and move to the next grade level
- Inform UBP staff of any academic difficulties I may have that may prevent you from maintaining an average of 2.5.
- Enroll in college preparatory courses while in high school
- Participate in UBP activities scheduled in the academic year. This includes traveling to Penn State, meeting at school, and completing online assignments as needed.
- Attend the 6-week summer program, at least once before grade 12.
- Enroll in college for the fall after high school graduation.
Student Name:

First NameLast Name
Student's Signature:

Clear
Date Signed:

MonthDayYear
mm-dd-yyyy
Parent / Guardian Consent
What services would your child benefit from? Please check all that apply:

6-week residential summer program focusing on academic enrichment and college preparationHelp choosing a career and/or college majorAssistance with financial aid and scholarshipsCollege and university toursSAT and/or ACT preparation and registrationRegular review of academic progress/gradesCollege Information & acceptance proceduresAssistance with high school course selection
Participation Consent: I give consent for my student to participate in the activities of Upward Bound Programs of Penn State University, both educational and social, which may include, but are not limited to, academic classes, field trips, testing, tutorial sessions, individual and group academic support and/or virtual programming as required by the program. I understand that my student is required to participate in activities scheduled throughout the academic year, which include traveling to Penn State via UBP sponsored transportation, meetings at their school, and completing assignments online as needed.

Information Release: I authorize and permit the release of all of my student’s academic records from their current school, as well as any schools attended in the past or in the future, to Upward Bound Programs. This includes, but is not limited, to, grades, transcripts, individual education and standardized test scores (PSSA, KEYSTONE SAT, etc), and proof of high school and/ or college graduation for the purpose of compiling and reporting data to the United States Department of Education, Office of Post-Secondary Education annually.

I understand that the United States Department of Education requires Upward Bound Programs at Penn State University to report on my academic progress through my high school years, graduation from college, and/or for at least four years after my expected high school graduation. I understand that these materials will be used to identify qualified UBP participants and monitor academic progress. I also grant continued access to all my student’s academic records if he or she leaves the program prior to graduating from high school. This complies with the Family Educational Rights and Privacy Act of 1974 (Public Law 93 - 80, Section 513(b)(4)(a). I understand these records are confidential and will only be used to meet the U.S. Department of Education’s regulations and program evaluation.
Drop-Off and/or Pick-Up Authorization Use for in-person programming only

Please list the names of people including parent/legal guardian that have permission to drop-off and/or pick-up your child.
Adult Name:

First NameLast Name
Phone Number:
(999)999-9999
Adult Name:

First NameLast Name
Phone Number:
(999)999-9999
Adult Name:

First NameLast Name
Phone Number:
(999)999-9999
Adult Name:

First NameLast Name
Phone Number:
(999)999-9999
The above individuals will be asked to verify their identity by showing an official picture ID before your child will be released into their care.

If there are any legal issues related to custody that we should be aware of, please provide us with an updated court document stating as such. We will abide by legal documents only when dealing with children and custody issues. Otherwise, either parent has equal rights to their child.
Special drop-off/pick-up instructions:
Codes of Conduct Use for Virtual Programs
I understand that my child will be subject to the rules and standards of conduct and the Pennsylvania State University when participating in a virtual program environment. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff or University employee may result in my child’s dismissal from the Program.
Codes of Conduct

I understand that my child will be subject to the rules and standards of conduct of The Pennsylvania State University (“Penn State” or the “University”) when participating in a University-sponsored program. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff or University employee may result in my child’s dismissal from the Program.
Title IX Policies & Procedures and Reporting Concerns

All Penn State youth programs have policies in place to ensure the safety of youth participating in our programs, activities and services is not compromised. All program staff are trained in emergency protocols and all relevant internal, external, and parental reporting requirements.

Title IX prohibits sex discrimination (including sexual harassment and/or sexual abuse) against Youth Participants in any of the University’s education programs or activities, including recreational and/or athletic programs or services operated by the University. Please click here to review the University’s Title IX policy and procedures.

To report an incident of suspected sex or gender-based discrimination, please contact Penn State’s Title IX

Coordinator, using the contact information below:

      Suzanne C. Adair, Interim Title IX Coordinator

      328 Boucke Building, University Park, PA 16802

      Phone: (814) 863-0471

      Email: sca917@psu.edu or titleix@psu.edu

or submit the Online Reporting Form.

Parents are encouraged to notify the program director immediately if they, or their child, are experiencing problems, difficulties, or concerns with the program, other youth in the program, and/or staff. You may also contact Sandy Weaver, Youth Programs Compliance Specialist at stw126@psu.edu or (814) 865-8785 or call the University's Ethics Hotline at 1-800-560-1637.
Liability Release: I/we, the undersigned, individual and as parent(s) and or legal guardian(s) of the above-named child, a minor, give permission to participate in the Upward Bound Academic Year Program and Summer Academy, sponsored by Upward Bound Programs of The Pennsylvania State University located at University Park and other Commonwealth Campuses throughout the year and pursuant to the Acknowledgments set forth above. In consideration of such admission, I/we do hereby agree to release, discharge, and hold harmless The Pennsylvania State University, its trustees, officers, agents, and employees of and from all actions, causes, lawsuits, liabilities, damages, claims, or demands whatsoever on account of any injury, accident, or illness involving the said minor and/or me arising out of my child’s participation in Upward Bound Programs.
Media Release: I/we...

Grant...Do not grant...
permission to The Pennsylvania State University and its agents or employees to use photographs and/or video, taken of my child from this event for use in promotional and educational materials and to use such photographs/video in publications, websites, articles, brochures, books, magazines, newsletters, exhibits, broadcasts, videos, films, social media, advertisements, and training programs in any form now known or later developed. I hereby agree to release, indemnify, and hold harmless The Pennsylvania State University and its agents or employees, including any firm publishing and/or distributing the materials in whole or in part, in any medium, from and against any claims, damages, or liability arising from or related to the use of the photographs/video.
Use of On-line Programs and/or Portals Use for in-person or virtual programming when appropriate.
I understand that Upward Bound Programs/equity.psu.edu is a federally-funded program that helps high-school students gain academic skills and motivation to continue their education beyond high school. I have read and reviewed the Upward Bound Programs/equity.psu.edu privacy policy at https://www.psu.edu/web-privacy-statement/ and allow my child to register online without additionally notifying me. I understand that my child will have the voluntary option to share any results with The Pennsylvania State University and, should such option be elected, I/we grant to The Pennsylvania State University the right to view all such results.
Use of Technology
I/we understand that upon acceptance into Upward Bound Programs, the above-named child will be receiving a new Chromebook-type device from UBP, free of charge, to use throughout their participation in academic year and summer programming and then to keep as their own for academic purposes. Neither The Pennsylvania State University nor Upward Bound Programs are responsible for this device, its upkeep, service, or repairs, after it is received by the student, parent, or guardian.
Parent / Guardian Name:

First NameLast Name
Parent/Guardian Signature:*

Clear
Date Signed:

MonthDayYear
mm-dd-yyyy
Teacher Recommendation
Please provide Upward Bound Programs with the names and contact information of a MATH, ENGLISH, and SCIENCE teacher that you have, or have had in the recent past, who can tell us about your academic strengths and potential.if you do not have their email address, we will contact them.
Math Teacher's Name:

First NameLast Name
Math Teacher's Email:
example@example.com
Science Teacher's Name:

First NameLast Name
Science Teacher's Email:
example@example.com
English Teacher's Name:

First NameLast Name
English Teacher's Email:
example@example.com
The Pennsylvania State University Youth Program Consent for Treatment
This form must be completed and returned before youth camp/program/event enrollment dates in order for youth to be permitted to participate in any program activities.
Personal Information
Youth's Name:

First NameLast Name
Birthdate:

MonthDayYear
mm-dd-yyyy
Gender:

MF
Specify program your child will be attending:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
(999)999-9999
E-mail Address:
example@example.com
Parent Guardian #1:

First NameLast Name
Daytime Phone:
(999)999-9999
Place of employment:
Parent Guardian #2:

First NameLast Name
Daytime Phone:
(999)999-9999
Place of employment:
Medical Information/History, Assumption of Risk, and Healthy Attendance Policy
Is physician authorization needed?

YesNo
Name of Family Physician:

First NameLast Name
Phone:
(999)999-9999
In case of emergency, please notify

If neither parent nor guardian is available in an emergency, please contact:
Name:

First NameLast Name
Phone:
(999)999-9999
Name:

First NameLast Name
Phone:
(999)999-9999
Health History

[Please check and provide approximate dates that youth suffered from allergies and other conditions listed below]
Allergies:

Hay FeverBee/Wasp StingsInsect StingsPenicillinPeanutOther
Date(s):

MonthDayYear
mm-dd-yyyy
Other:

AsthmaDiabetesConvulsionsConcussionBehavior/EmotionalOther
Date(s):

MonthDayYear
mm-dd-yyyy
Date of most recent tetanus immunization:

MonthDayYear
mm-dd-yyyy
Please list any major past illnesses (contagious and non-contagious):
Please list any major operations or serious injuries (include dates):
Has the youth ever been hospitalized?

YesNo
Does the youth have any chronic or recurring illness?

YesNo
Is there anything else in youth's health history that the program staff should know?
Are there any activities from which the youth should be restricted?

YesNo
Are there any specific activities that should be encouraged?

YesNo
Does the youth have any special dietary restrictions?

YesNo
Does the youth wear any medical appliances (glasses, contact lenses, orthodonture, etc.)?

YesNo
Will the youth need to take any medication during the program?

YesNo
If at all possible, medication should be administered at home. Medications will be allowed at the Youth Program only when failure to take such medicine would jeopardize the health of a child and he/she would not be able to attend the Youth Program if the medicine were not made available.
Youth's Name:

First NameLast Name
Birthdate:

MonthDayYear
mm-dd-yyyy
Gender:

MF
- I understand that all Youth Program participants are recommended to have a meningococcal vaccination prior to attending the program.
- I acknowledge and agree that attendance at any public event, including Youth Programs, involves certain unavoidable risks such as exposure to or infection by transmissible diseases, viruses, and other illnesses (including, but not limited to, COVID-19 and its variants). On behalf of myself and my child, I assume any and all such risk and acknowledge that such exposure or infection may result in personal injury, illness, severe complications, permanent disability, and/or death to my child or others. I agree on behalf of myself and my child to adhere to all applicable University policies including, but not limited to, those intended to mitigate the spread of transmissible illnesses. I understand it is my and my child’s responsibility to practice basic health, safety, and sanitation measures to avoid contracting or spreading transmissible illnesses. I further agree that my child will not attend the event if they are symptomatic of any commonly spread transmissible illness.
- In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency and if I cannot be reached, I give my consent for Penn State University Health Services staff or other licensed health care practitioners to perform any necessary emergency treatment.
- I hereby authorize the clinical staff at The Pennsylvania State University (“Penn State” or the “University”) (e.g., clinical staff at Penn State’s University Health Services) or other licensed health care practitioners, acting within the scope of his or her practice under State law, to provide medical care that includes routine diagnostic procedures (e.g., x-rays, blood and urine tests) and medical treatment as necessary to my minor daughter/ son/dependent. I understand that the consent and authorization herein granted does not include major surgical procedures and is valid only during the Youth Program/event.
- I agree to the release of records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider. If treatment is provided by Penn State, I understand that the University charges for services and that it is my responsibility to pay the bill. I may be responsible to submit any claims to my health insurance carrier for reimbursement. I also authorize Penn State to receive medical/billing information and submit it to the University’s insurance carrier.
- I understand that, unless specifically stated otherwise in the Penn State Youth Program/event literature, Penn State does not provide medical insurance to cover emergency care or medical treatment of my child.
- Medical and Related Health Information Penn State is committed to protecting the medical and related health information about your child. Medical and related health Information provided on this form will only be used as Penn State deems necessary to provide services for your child while participating in the Youth Program. Information will be stored, archived, and disposed of according to Policy AD35, University Archive and Records Management and Policy AD95, Information Assurance and IT Security.
- If there are any changes to your child's health, please contact the youth program.
Medication Management Use for in-person programming only
- It is NOT permissible for a participant to share any medications with any other participants. If at all possible, medication should be administered at home. Medications will be allowed at the Youth Program only when failure to take such medicine would jeopardize the health of a child and he/she would not be able to attend the Youth Program if the medicine were not made available.
- The parent(s)/legal guardian(s) of Youth Program participants are required to disclose their intention to bring medications to the Program, especially to treat potentially life-threatening conditions (i.e. inhalers, EPI-pens, insulin injections). Upon arrival to the Program, parent(s)/legal guardian(s) should plan to meet with a member of the Youth Program staff at registration to review medication issues for a Youth Program participant and complete additional required paperwork if not completed prior to arrival.
- All medications (prescription and over-the-counter) must be stored in the original product packaging and clearly labeled with the participant’s name. Prescription medication(s) must also include a label with the medication’s name and dosage instructions, as well as the prescribing physician’s name and telephone number.
- All medications will be kept in a securely locked cabinet used exclusively for storage of medications. Medications that require refrigeration will be stored and locked in a refrigerator designated for medications ONLY. Access to all medications will be limited to approved personnel. The need for emergency medication may require that a Youth Program participant carry the medication on his/her person or that it be easily accessed (i.e. inhalers, EPI-pens, insulin injections, seizure medication). Penn State Youth Program staff will NOT purchase medications of any type (prescription or over-the-counter) for Youth Program participants of any age.
- Penn State youth program does not carry over the counter medication. If a Program has professional medical staff on-site, then the medical staff may administer over the counter medications (e.g., ibuprofen or Tylenol) supplied by the parent(s)/guardian(s) per package instructions. Medical staff may monitor the self-administration of medications, if necessary, upon written consent of the parent(s) and/or legal guardian(s) and/or physician orders.
- If there are no medical staff on-site, Penn State Youth Program staff will not dispense medications, but may monitor the self-administration of certain medications if necessary, ONLY upon written consent of the parent(s)/legal guardian(s) and /or physician’s orders.
- It is the responsibility of the parent(s)/legal guardian(s) to be sure that the participant’s medications brought to the Youth Program are not left behind at the end of the Program. Failure to do so will result in the medications being destroyed within three working days after the participant’s last day at the Program. Absolutely no medications will be returned via mail regardless of circumstance.
- I understand that, in accordance with Youth Program policy, any medication(s) should be given at home before and/or after the Youth Program. However, when this is not possible, and medications will be brought to Youth Program camp, I agree to the provisions outlined above relating to the management of medications.
Will the youth be bringing any medications to be taken during the program?

NOYES

If YES, please list the specific prescription or over-the-counter medications below, reasons for medication, and daily dosage. If any medications change prior to arriving at the program, please provide an updated list upon arrival.

	Medication	Reason(s) for Medication	Daily Dosage/Time(s) Taken
1.
2.
3.
4.

For identification purposes, a current picture of the child is to be provided upon registration.
Parent/Legal Guardian Name:

First NameLast Name
Parent/Guardian Signature:*

Clear
Date:

MonthDayYear
mm-dd-yyyy
*Terms and Conditions agreed to via electronic signature

Student Application for Services

Student Contact and Demographic Information

FOSTER- OR STEP-PARENT / GUARDIAN

STUDENT CITIZENSHIP STATUS

INFORMATION ON HOUSEHOLD AND INCOME

Student Consent

Parent / Guardian Consent

Drop-Off and/or Pick-Up Authorization Use for in-person programming only

Codes of Conduct Use for Virtual Programs

Use of On-line Programs and/or Portals Use for in-person or virtual programming when appropriate.

Use of Technology

Teacher Recommendation

The Pennsylvania State University Youth Program Consent for Treatment

Medical Information/History, Assumption of Risk, and Healthy Attendance Policy