TRIO Upward Bound Program

The Upward Bound Program at Baldwin Wallace University is funded by a federal grant from the U.S. Department of Education. For questions and other information, please contact the TRIO Upward Bound Program office at (440) 826-2208.

Please complete all blanks. This should be completed by the parent/guardian with whom the student lives with, or by the parent/guardian providing at least 50% of student’s financial support.

Number of people in household:

Insurance Information

Medical and Media Release

I, the undersigned, am the parent/guardian of the above named minor. I hereby consent to his/her participation in the Baldwin Wallace Upward Bound Program and the activities planned in conjunction with this program. I understand that such activities may include social and recreational activities and the transportation of the above named minor to and from such activities. I am aware of the special needs and risks for these activities, which may include physical fitness of the participant.

I hereby recognize that there are personal injury risks involved with respect to the activities completed in the program, including risks inherent to the supervision of a group of young persons. I hereby assume such risks and release Baldwin Wallace University, its agents, employees, and students from any liability arising out of injury or accident which may be sustained by the above named minor.

I understand that in the event of a medical emergency, attempts will be made to contact me and if said attempts are not immediately successful that the supervisors of the Upward Bound Program may refer the above named minor to a licensed medical practitioner and/or the University Health Center, or hospital and hereby consent that such physician, Health Center, or hospital may treat the said minor in response to the medical emergency.

We may take photographs of the children during the process of their participation in the Baldwin Wallace University Upward Bound Program.

The media may visit our program. The media may take photographs, film footage, conduct interviews, or use children’s quotes. Children who participate in the Baldwin Wallace University Upward Bound may appear in these images or productions. These products and or public releases may appear on television locally or nationwide.

I have read and understand the condition of use as listed above. I understand that websites are able to be viewed worldwide. I grant to the Baldwin Wallace University Upward Bound the right to edit, use and reuse the above mentioned images and images of student work or products for non-profit purposes. I also hereby release the Baldwin Wallace University Upward Bound and its agent and employees from all claims, demands, and liabilities in connection with the above.

CERTIFICATION OF INFORMATION AND RELEASE STATEMENT

I hereby certify that the information in this application is correct and true to the best of my knowledge and herby authorize the Upward Bound Program at Baldwin Wallace University to release and receive information to assist my son/daughter with his/her educational planning. I understand that any false or misleading information may result in disqualification of the applicant.

I, the undersigned, attest that I am the parent/guardian of the above named minor. I do hereby give my permission for the above high school, educational institution or program to release grades, transcripts, test scores, individual education plans, and other relevant information to Baldwin Wallace University Upward Bound Program, upon request of the program or its representative. It is understood that the information is requested to assist staff of my child. I understand that the Upward Bound Program will hold this information confidential.

I fully understand that my records are protected under federal and state confidentiality regulations and cannot be released or disclosed without my written consent. I understand the reason(s) the information indicated above is being requested. Finally, I understand that I may revoke this consent at any time. However, any information shared prior to revocation of consent fails within the bound of this release.

This information has been disclosed to you from records whose confidentiality is protected by the Federal law. Federal regulations prohibits any further disclosure of it without the specific written consent of the parent or legal guardian to whom it pertains, or as otherwise permitted by such regulations.