300924-Hughes Elite Scholars-UB 1-Application Form-Stephen

Hughes Elite Scholars Inc. Upward Bound Program
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Upward Bound is a grant funded college-prep program implemented collaboratively by Hughes Elite Scholars Inc, (HESI) Gaston, Mecklenburg, Rowan and Stanly counties school personnel. At no cost to the family, Upward Bound provides a variety of college related activities as well as academic support to students’ year around.

Program activities include:
- Tutoring offered directly after school twice per week
- Saturday Session from 9am to 12pm offered twice per month at HESI or Schools- workshops including financial aid and scholarship information, academic and career advising, college and career research, guest speakers and more
- Field trips and college campus tours throughout the year
- Opportunities to earn college credit prior to attending college (all tuition and fees are paid for by grant funding)
- Six-week summer academy on college campus opportunity
- Student service-learning events
- Transportation to and from activities
- Breakfast and lunch provided (Saturday Academy)
- STEAM driven activities (Science, Technology, Engineering, Agricultural and Mathematics)
APPLICATIONS WILL NOT RECEIVE CONSIDERATION UNLESS THE ENTIRE PACKET IS COMPLETED

RETURN APPLICATION TO YOUR GUIDANCE COUNSELOR OR MAIL TO:

HUGHES ELITE SCHOLARS Inc. UPWARD BOUND PROGRAM
10150 Mallard Creek Road Suite 106
Charlotte, North Carolina 28262

TRIO Upward Bound Program is a nationwide federally funded college-preparatory program that serves first generation college-bound high school students and/or students who reside in income-eligible households. Program benefits include individual academic tutoring, group and individual advising, cultural field trips,
college tours, financial aid literacy, career planning/guest speakers, Saturday workshops, and annual summer academy.

The HESI Upward Bound program serves 180 students each year from eight high schools in Gaston, Mecklenburg, Rowan and Stanly counties.
Program eligibility is listed below.
- Must be a citizen of the United States or a permanent resident.
- Must be either or both:
  - Meet federal income guidelines for TRIO programs.
    https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html
  - A first-generation college student (the parents/guardians with whom the student lives has not earned a bachelor’s degree)
- Must be a rising or current 9th, 10th, 11th grade student enrolled at one of the following schools:
  - Albemarle High School-Stanly County
  - Ashbrook High School-Gaston County
  - East Mecklenburg High School-Mecklenburg County
  - Forestview High School-Gaston County
  - Harding University High School -Mecklenburg County
  - Hunter Huss High School-Gaston County
  - North Rowan High School-Rowan County
  - Rocky River High School-Mecklenburg County
  - Salisbury High School-Rowan County
Please complete the following pages of the application and return it to your guidance counselor, or Upward Bound staff directly. As applications are submitted, UB staff will contact each student regarding a brief interview and next steps. You are welcome to contact staff with further questions.

Tamesha Hughes-Frazier
Executive Director

Confidentiality and Information Assurance
The personal information requested of you in the Upward Bound Application and by the Upward Bound staff is a requirement of the U.S. Department of Education and is considered necessary to substantiate your eligibility to participate.

The Federal Privacy Act protects this information. No one may view this information, unless they work for the Upward Bound Program, or are otherwise specifically authorized to see information.

The information on the HESI Upward Bound application is used to determine whether students are eligible for the Upward Bound program. Admission into the program is based upon eligibility, need, and readiness for the program. We may not admit every student who is eligible, depending on the number of applications received.
- Full Name:
  
  First NameM.I.Last Name
- Sex
- Date of Birth:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Age:
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Student School ID#:
- Home Phone:
  (999)999-9999
- Student Cell Phone:
  (999)999-9999
- Student Personal e-mail:
  example@example.com
- Student Citizenship Status: (Please check one)
  
  Other
- Ethnicity: Are you Hispanic or Latino?
- What is your race? (Choose all that apply)
  
  Other
- Which high school do you attend?
  
  A Different High School
- Current Grade:
- Expected Graduation Year:
- Do you plan to attend college after graduating from high school?
- How did you hear about the Upward Bound program?
- Do you plan to work this school year or next summer?
- If yes, when?
- Estimated hours per week:
- Student Certification:
  I, {main_name}, applicant for admission to the Hughes Elite Scholars
  Inc. Upward Bound Program, verify all the information within this entire application, to the best of my knowledge, is factual and that no information was presented with any intent to defraud.
- Student Applicant Signature
- Student Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Student Applicant Information:
- Child’s Name:
  
  First NameLast Name
- High School
- Natural or Adoptive Parent / Legal Guardian 1:
- Name
  
  First NameLast Name
- Sex
- Occupation/Job Title:
- Has this person earned a (4 year) bachelor’s degree from an accredited institution?
- Parent/guardian email:
  example@example.com
- Parent’s Cell Number:
  (999)999-9999
- Parent’s Home Number:
  (999)999-9999
- Natural or Adoptive Parent / Legal Guardian 2:
- Name
  
  First NameLast Name
- Sex
- Occupation/Job Title:
- Has this person earned a (4 year) bachelor’s degree from an accredited institution?
- Parent/guardian email:
  example@example.com
- Parent’s Cell Number:
  (999)999-9999
- Parent’s Home Number:
  (999)999-9999
- Household Income Information:
- With whom does the applicant live?
- Total number of people in the household (including those away in college)
- Total annual gross income for all parent(s)/guardians(s) living with the student:
  $
- Total taxable income (adjusted gross income – deductions and exemptions):
  $
- This is featured on line 15 of the 1040 form
- At school, your child receives:
- Primary language spoken at home:
  
  Other
- Parent Certification (required):
- I, {name}, parent/guardian of {main_name}, verify that all of the information in this application for Hughes Elite Scholars Inc. Upward Bound Program is, to the best of my knowledge, factual and that no information was presented with any intent to defraud.
- Parent/Guardian Signature
- Parent/Guardian Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- PLEASE CHECK ALL THAT APPLY. (You may check more than one in each category)
- Career Choices/Planning:
- My career choice is:
- I would like information on the following careers:
- Tutoring/Academic Assistance:
- My grade point average is:
- I would like a tutor to assist me with:
- College/University Choice:
- I would like information on the following colleges:
- My college choice is:
- I plan on obtaining:
- Financial Assistance:
- Counseling:
- As part of the selection process, the Upward Bound Program asks each student to tell us in writing about yourself and your interests, why you want to participate in UB, and what reasons you have for attending college or another post-secondary training program after high school. Be specific and tell us in at least 200-500 words as much about yourself as possible. Not only will this writing sample be used for selection, but it will also be used to determine how we can help you develop your writing skills.
- Essay Upload
  
  Cancelof
- As a federally funded educational program, Upward Bound is required to maintain student records. Under rules established by the Family Educational Rights and Privacy Act, (FEPRA) you are hereby notified the programs student records, and the information they contain are kept confidential, and the student (and your parents, if the student is younger than 18 years) have the right to inspect the contents of your records.
  
  I authorize the release of school records for my son/daughter’s file that may be requested by the Hughes Elite Scholars Inc. Upward Bound Program. I understand the U.S. Department of Education funds the HESI Upward Bound Programs and will use these records to provide academic advisement for my son/daughter. I also understand these records are handled in a confidential manner and they are only available to program staff and representatives from the Federal and State Department of Education.
  
  As indicated below, please initial the statement if you agree:
- I hereby give permission for the release of any records from my child’s file to the Hughes Elite Scholars Inc. Upward Bound Program [Parent or Legal Guardian].
- This authorization will provide the following records to be shared with the HESI Upward Bound Program:
  - Official school transcript and/or college transcripts, test scores and/ or grade promotion or graduation.
  - High School Assessment (EOC), Standardized test results (PSAT, SAT, ACT, etc. if available), Advanced Placement (AP) or International Baccalaureate (IB) test scores.
  - Request a copy of financial aid applications and awards from Federal Government, state funding agencies, and post-secondary institutions.
  - Student grades/progress reports, Information regarding special accommodations.
  - Information concerning disciplinary actions.
  - Communicate with representatives from agencies or post-secondary institutions on my behalf.
- Student’s Full Name:
  
  First NameLast Name
- Student’s High School:
- Student’s ID Number:
- Student’s Date of Birth:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Parent or Guardian’s Name:
  
  First NameLast Name
- Note: A photocopy of this Consent to Release Information Form should be accepted as an original and the date indicated below has no bearing on when the information is requested by the HESI Upward Bound Program
- Parent/Guardian Signature
- Parent/Guardian Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- My signature below indicates I am providing consent for my son/daughter to utilize the Internet for educational purposes in accordance with the Acceptable Use Policy of Hughes Elite Scholars, Inc. Additionally, I agree and consent to allow the photographs, and/or audio/video recordings taken or created during the Upward Bound activities to be placed on the web and in public information materials. I further agree to allow the UB program to release, for educational purposes, photographs, and video recordings, with or without audio, of program activities and projects including my child and/ or likeness. I agree that the use herein may be without compensation to me or my child. I hereby waive any right to inspect or approve the finished electronic, photograph, or printed matter that may be used in conjunction with them now or in the future. I am expressly releasing Hughes Elite Scholars, Inc, its agents, employees, licensees and assigns from any and all claims which I may have for invasion of my child’s privacy, right of publicity, defamation, copyright infringement, or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast, or exhibition of such recordings.
- Student Participate
  
  First NameLast Name
- Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Parent/Guardian
  
  First NameLast Name
- Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- In consideration for being allowed by Hughes Elite Scholars, Inc., to participate in the Upward Bound Program the undersigned custodial parent/guardian hereby agrees as follows:
  
  I do hereby affirm and acknowledge that my child is participating in the Program for his/her own personal benefit and have been fully informed of the inherent hazards and risk to them associated with this activity including property damage, falls, contact with other participants, motor vehicle accidents, sprains, and other
  personal injuries. I accept and assume responsibility for all risks, known and unknown, involved to my child and their property in the aforementioned activity, and I voluntarily authorize my child’s participation in reliance upon my own judgement and knowledge of my child’s experience and capabilities.
  
  I understand that the determination of my child’s ability to participate in the Program should be made by my child’s physician if necessary. I understand that I need the approval of a physician if I am uncertain as to his/her physical fitness for the rigors of this Program. I understand that I may be required to seek approval from physician if there is a health safety question relative to my child’s condition before being allowed to participate in the Program. In addition, I give permission to any doctor, hospital, or other medical facility to release confidential to the treating physician(s) for my child any information they may have concerning his/her medical condition and their professional contact with him/her for treatment purposes. I hereby grant my permission for such diagnostic, therapeutic, and operative procedures as deemed necessary for child. A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.
  
  I shall indemnify and hold harmless Hughes Elite Scholars Inc., and its trustees, officers, employees and agents from any liability, losses, costs, damages, claims or causes of action of any kind or nature whatsoever, and expenses, including attorney’s fees, arising from, or proximately caused by my child’s participation in this Program, including any travel. I further agree to accept and assume for myself, my assigns, executors, and heirs any and all such risks and losses that may occur.
  
  I have read the Program’s rules and regulations and hereby accept the regulations of the Program described therein. I understand that the Program has the authority to establish and enforce other regulations in addition to these.
  
  I understand that this is a legal document which is binding on me, my heirs and assigns and on those who may claim by or through me. I am eighteen years of age or older, have full capacity to enter into this agreement and do so voluntarily.
  
  I HAVE READ THIS AGREEMENT, I UNDERSTAND IT AND I AGREE TO BE BOUND BY IT.
- Signature of Parent/Guardian:
- Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Name:
  
  First NameLast Name
- Name of Child:
  
  First NameLast Name
- School
- Please list any and all physical conditions that your student may have which might affect or be affected by participation in this program in which the Upward Bound Staff should know.
- Present medical problems or conditions:
- Medical taken regularly:
- Allergies (Including allergies to medications):
- MEDICAL RELEASE For
- Name
  
  First NameMiddle NameLast Name
- A student in the Upward Bound Program
  
  I do____ hereby grant permission to the Executive Director of Upward Bound, or the Executive Director’s authorize representative, to furnish first aid as my child (named above) may require, as well as to seek medical attention through the nearest medical facilities such as those provided on campus and those medical facilities available when students are on field trips and other authorized activities.
  
  This permission is conditioned upon the understanding that, in the event of serious illness or the need of hospitalization and/or major surgery, the Executive Director from providing such emergency treatment as any be necessary for the Best interest of the life of my child. A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.
- Parent / Guardian Signature
- Parent/Guardian Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- IN CASE OF AN EMERGENCY, NOTIFY:
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- HOME PHONE
  (999)999-9999
- WORK #
  (999)999-9999
- CELL #
  (999)999-9999

Hughes Elite Scholars Inc. Upward Bound Program