288721-Sinclair Community College-UB 2-2023 Application Form 2 Part 2-Joseph

Sinclair Upward Bound Application - Part Two - Dunbar and Thurgood
Please be sure to enter all information accurately.

For any questions, please email sinclairupwardbound@gmail.com or call 927-512-2331
Student's First Name, Middle Initial, and Last Name*

First NameMiddle InitialLast Name
Parent/Guardian Information
Please be sure to enter all information accurately.

For any questions, please email sinclairupwardbound@gmail.com or call 927-512-2331
Parent/Guardian's First Name and Last Name*

First NameLast Name
Parent/Guardian's Relationship to the Student*
Parent/Guardian's Phone Number*
(999)999-9999
Parent/Guardian's Email Address*
example@example.com
Parent/Guardian's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does either parent/guardian have a Bachelor's Degree? (four year degree)*

YesNo
How many people live in the parent/guardian's household? (including the student)*
What is the Family's Taxable Income?*

$0-$22,590$22,591-$30,660$30,661-$38,730$38,731-$46,800$46,801-$54,870$54,871-$62,940$62,941-$71,010$71,011-$79,080$79,081 and up
What is the Income Tax Filing Status?*

SingleMarried filing separatelyMarried filing jointlyUnmarried/head of household
Does the parent/guardian give Sinclair Upward Bound permission to text and/or email them?*

YesNo
What language does the parent/guardian prefer Sinclair Upward Bound communication (text, emails, etc.) to be sent in?

EnglishSpanishOther
STUDENT/PARENT/GUARDIAN RELEASE AUTHORIZATION

By my signature below:
- I certify that the above information is correct and true to the best of my knowledge.
- I agree that Sinclair Community College, Upward Bound staff, or volunteers associated with the college will not be held liable for any loss, injury, or death related to any field trip, activity, or event.
- I authorize the Upward Bound staff access to any and all academic records/transcripts/social security numbers available from the school the student/applicant attends for the purpose of determining eligibility and providing educational services.
- I authorize and permit my child to participate in field trips, activities, and events sponsored and conducted by Upward Bound.
- I grant permission for my child to access networked computer services such as the Internet, World Wide Web, and electronic mail.
- I grant permission to the Upward Bound program to use images of my child for the purpose of promoting the Upward Bound program and Sinclair Community College.
- In the event that my child is involved in a medical emergency, I authorize Upward Bound staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc.), if I am unable to be contacted or reached for verbal authorization.
Parent/Guardian’s Signature*

Clear
Additional Student Information
Please be sure to enter all information accurately.

For any questions, please email sinclairupwardbound@gmail.com or call 927-512-2331
Student's Social Security Number (This is needed for students to receive their stipend checks.) Please put 000-00-0000 if the student does NOT have a Social Security Number.*
999-99-9999
If student does NOT have a Social Security Number, please enter the student's United States Citizenship and Immigration Services Number and/or a related number that would take the place of a student's Social Security Number. (Please refer to "645.3 Who is eligible to participate in an Upward Bound project?" to see who is eligible to participate in the Sinclair Upward Bound Program.)
Student's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's PERSONAL Email Address (Please do not put the student's Dayton Public Schools email address and please enter an email address that can be accessed by the student at all times and can receive emails)*
example@example.com
Is the student an United States citizen?*

YesNoOther
Is the student an English as a Second Language/ELL student? (this applies to students whose first language is NOT English)*

YesNoOther
What is the student's t-shirt size? (in accordance to adult t-shirt sizes)*

Extra Extra SmallExtra SmallSmallMediumLargeExtra Large2X3X4X5XOther
Student's School Student ID Number (if applicable)
Student's Dayton Public Schools Home Access Center (HAC) Username (if applicable)
Student's Dayton Public Schools Home Access Center (HAC) Password (if applicable)
Has the student completed any classes through College Credit Plus, Career Technical Education, ROTC, etc.?

YesNoThe student is unsure.
Does the student receive free or reduced lunch?

YesNo
Is the student currently experiencing homelessness, in foster care, and/or involved in the juvenile justice system?*

YesNo

Student's Career Interests (Example: teacher, engineer, accountant, artist)

	Career Name
1
2
3

Briefly describe why the student should be accepted into the Sinclair Upward Bound Program. (this should be completed by the student)*
RECOMMENDATION FROM A TEACHER OR COUNSELOR
Along with completing this application, the student must select on a teacher or counselor to submit a recommendation on your behalf. Enter the teacher or counselor's name and email below (please make sure the email is spelled correctly!). For any questions, please email sinclairupwardbound@gmail.com or call 927-512-2331

IMPORTANT: Student's must follow up with their counselor/teacher to let them know what they need to complete the Upward Bound Recommendation Form.
Teacher/Counselor's Name*

First NameLast Name
Teacher/Counselor's Email Address (Please use the Dayton Public School's Staff Directory for guidance if needed.)*
example@example.com
Medical Information and Consent Form
THIS FORM MUST BE COMPLETED IN ITS ENTIRETY.

Purpose: This form enables parents (or a participant age 18 or over) to authorize emergency medical treatment in the event of illness or injury while the child is a participant in any activity or trip with Sinclair Community College and provides health information and medical insurance information about the child.

Some of this information may be a repeat from what was entered in the student’s application. Please fill out everything that is required. This is a separate document that is filed apart from the application, so that is why the information is needed twice. Thank you!
Please be sure to enter all information accurately.

For any questions, please email sinclairupwardbound@gmail.com or call 927-512-2331
Student's First Name, Middle Initial, and Last Name*

First NameMiddle InitialLast Name
Student's Social Security Number*
999-99-9999
Student's Date of Birth*

MonthDayYear
mm-dd-yyyy
Student's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's First Name and Last Name*

First NameLast Name
Parent/Guardian's Phone Number*
(999)999-9999
Parent/Guardian's Work Number
(999)999-9999
Parent/Guardian's Work Schedule
Alternate Person's First and Last Name (to contact if parent/guardian is unavailable in an emergency)*

First NameLast Name
Alternate Person's Phone Number*
(999)999-9999
Alternate Person's Relationship to the Student*
Preferred Hospital*
Family Doctor's First and Last Name

First NameLast Name
Family Doctor's Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Doctor's Office Phone Number
(999)999-9999
Dentist's First and Last Name

First NameLast Name
Dentist's Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist's Office Phone Number
(999)999-9999
Is the student covered by medical insurance?*

YesNo
First and Last Name of Insured Person

First NameLast Name
Name of Insurance Company
Insurance Group Number
Insurance Policy Number
If CareSource, please enter your Member Number, MMIS Number, and Case Number
Does the student have any of the following medical conditions that may affect emergency medical treatment?*

The student does not have any medical conditions that may affect emergency medical treatment.Allergy to medicationAllergy to food/environmentBlackout and/or faintingChronic diseaseDrug and/or alcohol addictionHearing/vision/speech impairmentEpilepsyHeart and/or lung problemsPhysical handicapsDiabetesOther
Please explain any of the medical conditions that were checked off.
Does the student take any prescribed medications?*

YesNo
Name of Medication
Dosage
Prescribing Physician

First NameLast Name
Physician's Phone Number
(999)999-9999
Name of Medication
Dosage
Prescribing Physician

First NameLast Name
Physician's Phone Number
(999)999-9999
Please list any other additional medication if necessary.
CONSENT FOR MEDICAL TREATMENT SIGNATURE
In the event that reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of medical treatment deemed necessary by licensed paramedics, physicians, or dentists and to have my child transported to the closest medical emergency facility accessible. This authorization DOES NOT COVER major surgery unless the medical opinions of two (s) physicians or dentists concurring on the necessity of life-saving surgery are obtained BEFORE the surgery is performed.
Parent/Guardian's First and Last Name*

First NameLast Name
Parent/Guardian's Signature*

Clear
Today's Date*

MonthDayYear
mm-dd-yyyy
If student is age 18 or over, they must also sign below.
Student's Signature

Clear
Today's Date

MonthDayYear
mm-dd-yyyy

Sinclair Upward Bound Application - Part Two - Dunbar and Thurgood

Parent/Guardian Information

Additional Student Information

Medical Information and Consent Form