UPWARD BOUND PROGRAM

Write an essay of AT LEAST THREE paragraphs on ONE of the following subjects.
Please Note: Upward Bound is a Saturday program during the academic year and attendance is mandatory.

A. Describe your neighborhood, mentioning how it looks, who lives there, what you like or dislike about it.

B. What do you hope to gain from your Upward Bound experience and what would you contribute to the UB program.

C. Tell us about a special circumstance which may have affected your performance in school and how you handled it. (Illness, family problems, peers, sports, etc.)

I CERTIFY THAT ALL THE INFORMATION ON THIS APPLICATION IS TRUE, COMPLETE, AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

I, {parentguardianName}, certify that the above information about {studentName} is correct to the best of my knowledge.

TO BE COMPLETED BY PARENT OR 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. Individuals who violate the privacy act shall be subject to a fine of not more than $1,000 or imprisoned no more than one year, or both, and shall be removed from employment.

ALL QUESTIONS MUST BE ANSWERED

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.

For family units with more than eight members, add the following amount for each additional family member: $6,630 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $8,295 for Alaska; and $7,620 for Hawaii.

The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

The figures shown under family income represent amounts equal to 150 percent of the family income levels established by the Census Bureau for determining poverty status. The 2019 poverty guidelines are in effect as of January 11, 2019. Federal Register notice forthcoming. Publication is delayed due to temporary closure of federal offices.

Source: Office of Post-Secondary Education—U.S. Department of Education

CONTACT NUMBERS

TO BE COMPLETED BY PARENT OR GUARDIAN

I authorize the staff of Upward Bound Trio Program to consent of medical treatment of such minor when I cannot be contacted to so consent; such medical treatment to include, without limitation, x-ray examination, anesthetic, medical, dental or surgical examination or treatment and general hospital emergency care. No prior determination of life-threatening emergency or danger of serious injury resulting from delay of treatment need be made under this authorization.

I Specifically Certify and Agree That:

Except as indicated at the end of this paragraph this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of the Adult to give specific consent to any and all such examinations, treatment and/or hospital care.

The possession of this Authorization by the Adult is evidence that he/she has care and control of such minor and that I cannot be contacted. I will indemnify and hold harmless from any expenses or claims of any nature and entity which provides or causes to be provided examination, treatment or hospital care pursuant to this Authorization (except to the extent such entity is negligent therein) and conditionally agree to make or cause to be made by assignment of third party benefits or otherwise, full and complete payment for such examination, treatment or hospital care.

I am the person having the power to consent to medical treatment of such minor. This Authorization shall remain effective for a period of one (1) year from its signing, unless sooner revoked by the physical destruction of the original hereof, such destruction being the only method of actual notice of the revocation of the same. All blanks of this Authorization were filled in before I signed this Authorization:

TO BE SIGNED BY THE STUDENT AND PARENT/GUARDIAN

The University of Houston-Downtown Upward Bound staff will provide the proper learning atmosphere, academic skills, counseling, and college guidelines to the students in the program. Altogether, 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, {parentName}, as an Upward Bound student promise to: attend all classes/tutorial sessions 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 the University of Houston-Downtown.

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.

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.

As the parent(s)/guardian(s) of {studentName149}, I am in agreement with the goals and purposes of the Upward Bound Program. I will participate in program activities during academic year and summer program. Also, I certify that I am responsible for all debts incurred, either by my child or myself, related to my child's participation in the Upward Bound Program.

MAIL 
University of Houston-Downtown
Upward Bound Program
One Main Street, Suite N-220
Houston, Texas 77002

FAX
Kennedy Bosie and Harvey Pittman
Program Advisors
Vicki Creeks-Lacy
Lead Counselor

UHD Upward Bound (713) 223-7461

EMAIL
Harvey Pittman
Pittmanh@uhd.edu 

Kennedy Bosie
Bosiek@uhd.edu 

Vicki Creeks-Lacy
Creekslacyv@uhd.edu 

 

PERMISSION TO OBTAIN SCHOOL RECORDS

I, {fullName161} give permission to the University of Houston-Downtown Upward Bound Program to request and receive education records, test scores, transcripts, and other documentation for the above named participant.

INSTITUTION;
University of Houston- Downtown
Dept. - Upward Bound Program
One Main Street, Ste. N-220, Houston, TX 77002

DESCRIPTION OF ACTIVITY OR TRIP: Local College Tours and Field Trips

LOCATION(S): Houston and Galveston Texas

DATE(S): September 30 , 2023 - July 26, 2024

 

I, above-named Participant, have voluntarily applied and/or agreed to participate in the above-described Activity or Trip (hereinafter referred to as the Activity or Trip"), which is associated with the above-named institution (hereinafter referred to as the "Institution"). I acknowledge that the nature of the Activity or Trip may expose me to hazards or risks that may result in my illness, personal injury, or even death, and I fully understand and appreciate the nature of such hazards and risks. Such risks may include, but are not limited to, illness, personal injury, or death that is caused from traveling via any means of transportation to and from the Activity or Trip and/or during the duration of the Activity or Trip, as well as engaging in activities or events that are typically associated with the Activity or Trip and related matters and activities, and being exposed to and/or using materials, tools, supplies machinery and/or equpment or other items that are typically found and/or used during the. Activity or Trip and relatld activities and being exposed to other dangerous conditions that are typically associated with the Activity or Trip and related activities. acknowledge that the Institution in no way represents, or acts as an agent for any entity including, but not limited to, transportation carriers or other suppliers of services connected with the Activity or Trip.

International Travel Provisions (if applicable): I recognize and understand that I will very likely encounter cultures and laws that are different from those in the United States, and Imay also encounter living and work conditions and/or standards that are different and/or significantly lower than those in the United States. If any problems arise with foreign nationals or the government of a foreign country, I agree to be fully responsible for resolving the matter and the Institution is not responsible for providing any assistance. I agree to obey and comply with all laws of the country(ies) in and through which I will be traveling and visiting, including local laws as well I also understand that I have access to international travel advisories, warnings, and general tips available to me through the United States Department of State located at http://travel.state.go/travel/, and I understand that health risks associated with any such travel are described in the Center for Disease Control Health Information located at http://www.nc.cdc.gov/trayel. I acknowledge that I have read this information as it pertains to the country(ies) in which I will travel as part of the Activity or Trip. I recognize that common liability insurance policies may not provide coverage outside of the United States and Canada. I understand that the Institution and the University of Houston System do not maintain any insurance policy covering any circumstances, ineluding, but not limited to, illness, personal injury or death, arising from my participation in the Activity or Trip or any activity or event in any way associated with or facilitating that participation.

Regardless of whether or not [ will be traveling internationally for the Activity or Trip, I agree to obey and comply with all applicable federal and state laws and Institution policies during the duration of the Activity or Trip, and am voluntarily and expressly assuming all risks associated with the Activity or Trip. For Institution policy information, see http://www.uh.edu/legal-affairs/general-counsel/resources-and-policies/index.php

I understand that I am responsible to obtain appropriate insurance coverage to cover any possible circumstance or injury resulting from my participation in the Activity or Trip I understand and agree that should I decide to drive an automobile or other motorized vehicle to and/or from the Activity or at any time during the duration of the Activity or Trip, I will maintain a proper and sufficient driver's license as well as automobile and/or related liability insurance to cover any act(s) or omission(s) on my part at any time while operating such automobile or other motorized vehicle, be it during my participation in the Activity or Trip or otherwise. I represent that I am physically and mentally able, with or without accommodation, to participate in all aspects of the Activity or Trip, am able to be in the presence of, as well as use, the machinery, tools, equipment, materials, and/or supplies
typically associated with the Activity or Trip, and have obtained all required immunizations.

In consideration of my participation in the Activity or Trip, I hereby accept and expressly assume all risk fo my health and of injury or death that may result from such participation, and I hereby release the Institution and the University of Houston System, the Institution and the University of Houston System'`s governing board, officers, employees, faculty members, representatives and agents (hereinafter collectively referred to as the *Released Parties"), in both their official and personal capacities, from any and all liability to me, my personal representatives, estate, heirs, next of kin, and assigns, for any and all claims and causes of action for loss of or damage to my property and for any and all illness(es) or personal injury(ies) to my person, including my death, that may result from or occur during and as a result of my participation in the Activity or Trip and/or any of the above mentioned activities, whether caused by negligence of the Released Parties or otherwise. I understand and agree that should I choose to engage in non-Activity or Trip related activities or events, that doing so is not part of the Activity or Trip, and further,I hereby accept and assume all risks to my health and of injury or death that may result from any participation in non-Activity or Trip related activities or events, and I hereby release the Released Parties from any and all liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness(es) or injury(ies) to my person, including my death, that may result from or occur during my participation in any non-Activity or Trip related activities or events, whether caused by negligence of the Released Parties or otherwise. I further agree to indemnify and hold harmless the Released Parties from liability for the injury or death of any person(s), and/or damage to property, that may result from my negligent or intentional act(s) or omission(s) while participating in the Activity or Trip and/or related activities and/or while participating in any non-Activity or Trip related activities or events.

I HAVE CAREFULLY READ THIS RELEASE AND INDEMNIFICATION AGREEMENT ("AGREEMENT") AND UNDERSTAND IT TO BE A FULL RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY, ILLNESS, OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE ACTIVITY OR TRIP AND/OR RELATED ACTIVITIES ANDOR WHILE PARTICIPATING IN ANY NONACTIVITY OR TRIP RELATED ACTIVITIES OR EVENTS, AND IT OBLIGATES ME TO INDEMNIFY THE RELEASED PARTIES  FOR ANY LIABILITY FOR INJURY, ILLNESS, OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT(S) OR OMISSION(S). I EXPRESSLY ASSUME ANY AND ALL RISKS ASSOCIATED WITH THIS ACTIVITY OR TRIP.

Should I require emergency medical treatment as a result of accident or illness arising during the Activity or Trip and/or related activities, I consent to such treatment. I acknowledge that the Institution and the University of Houston System do not provide health and accident insurance for participants in the Activity or Trip and I agree to be financially responsible for any medical bills incurred as a result of emergency medical treatment, I will notify Institution representatives in writing if I have medical conditions about which emergency medical personnel shouid be informed.

I agree that this Agreement shall be construed in accordance with the laws of the State of Texas, which shall be the forum for any lawsuit filed under or incident to the Activity or Trip and/or this Agreement. If any term or provision of this Agreement shall be held illegal, unenforeable, or in conflict with any law governing this Agreement, the valiidity of the remaining portions shall not be affected thereby. I expressly agree that this Agreement is intedned to be as broad and inclusive as permitted by the laws of the State of Texas.