UPWARD BOUND PROGRAM ∙ APPLICATIONS FOR ADMISSION

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 for and pay for college.

I verify all student information provided is correct.

Please identify one teacher and one counselor as a recommender for you to enter the program. Provide the contact information below for the project to email a Recommendation Form to each person listed

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 the 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 to determine eligibility

1. Household Income

Father or Male Guardian

Mother or Female Guardian

I certify that my signature acknowledges the above information is correct to the best of my knowledge.

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 of 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.

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.

RELEASE AND AUTHORIZATION TO PHOTOGRAPH
As the parent(s)/guardian(s) of ___________________________________, I agree 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.

Participant (student) Information:

(0 = Never Swam; 10 = Excellent)

Health, Medical and Emergency Contact Information

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.