Palm Beach State College-Glades Region-UB-2024 Application Form

Upward Bound Program

Glades Region

Parent-Student Information
What Is TRIO Upward Bound Glades Region?

Trio Upward Bound Glades Region is the ultimate roadmap to college. It is a free federally funded program that services students in grades 9th-12th at Glades Central and Pahokee
High School.

What does TRIO Upward Bound Glades Region do?

We assist with the steppingstones needed for college and a career. Services we offer include test preparation, academic advising, career exploration, and SAT/ACT prep. We will also offer educational trips such as college tours and onsite career exploration. Monthly stipends
are available to participants in the Upward Bound Glades Reg ion based on active participation.

Why should I be a part of the TRIO Upward Bound Glades Region program?

This program prepares students for navigating the roadmaps of college and careers as well as expanding their minds and experience on real world skill sets. By assisting with the transition proces of college and career preparation we are helping the Glades area students to achieve excellence.

TRIO UPWARD BOUND GLADES REGION

Team Contact Information

Deidra Moreland
Program Grant Director
Office 218 TEC
561-993-1438
moreland@palmbeachstate.edu

Alyssa Sanchez
Post-Secondary Advisor
Office 214 TEC
561-993-1439
sancheza@palmbeachstate.edu

Rickeria Lendale
Administrative Assistant
Office 214.1 TEC
561-993-1024
lendaler@palmbeachstate.edu

Mission Statement

To provide college and carreer succes opportunities through experiences and exposure that will guide students into the purpose and passion designed for their lives.

UPWARD BOUND GLADES REGION PROGRAM Application
Office (561) 993-1024 Cell (561) 680-9588 or (561) 680-9608
1977 College Dr.MS #43 Belle Glade, FL 33430
Email: upwardboundbg@palmbeachstate.edu

You MUST answer ALL questions clearly and completely. ALL ITEMS ON CHECKLIST MUST BE TURNED IN BEFORE APPLICATION IS REVIEWED (See back). If selected, prospective candidates will be interviewed.

ELILGIBILITY CRITERIA

The Upward Bound Glades Region Program (UBP) provides academic, financial, professional, and social support services to high school students to prepare them for college success. Applicants must meet the following requirements:
- Qualify under the U.S.Dept. of Education's guidelines as a member of a low-income household or a household in which
  neither supporting parent holds a baccalaureate degree.
- Meet U.S. residency requirements (citizen, permanent resident, applied for permanent resident) and be age 13- 19.
- Demonstrate an academic need and the motivation to pursue college.
- Attend one of the following target high schools: Glades Central High School or Pahokee High School

Medical Information and Authorization for Medical Care
Program Name: TRIO UPWARD BOUND GLADES REGION

Date(s) of Program: 2024-2025
Participant/Student Name:*

First NameLast Name
Parent/Guardian Name:*

First NameLast Name
Parent Phone Number:*
(999)999-9999
Health Insurance Information

(if available)
Insurance Provider:
Insurance Phone Number:
(999)999-9999
Policy Number:
Physician/Pediatrician Practice:
Phone Number:
(999)999-9999
(Note: Palm Beach State does not offer any form of health, liability, or other types of insurance for participants. If availble, please attach a copy of the front and back of your insurance card with this form.)
Insurance card

Cancelof
Medical Information
1. Medical information we need to know about your child (current conditions, physical limitations, past injuries, etc.)*
2. Allergies (medications, stings, foods, iodine, latex, etc.):*
3. Medications child is currently taking, dosage, and times taken:*
4. Does your child need any accommodations to participate in the program safely? If yes, please explain.*
Due to the State of Florida law, I understand that the Program staff CAN NOT administer my child the above-listed medication. I understand that medication, whether over-the-counter or prescription, must be kept in original containers with original labels. Students are responsible for administering their medication. Medication CAN NOT be shared among students. Program staff must know what medication each student has on their person at all times.

If you have a fever, body aches, or other flu-like symptoms, please remain at home for the safety of yourself and others.

Authorization for Medical Treatment

I consent to medical and/or surgical care as may become necessary for the Participant's well-being, should the need arise. I understand that I will be solely responsible for the cost. authorize the College to communicate in emergencies with the person(s) identified in my submission materials. I hold harmless and agree to indemnify the University from any claims, causes of action, damages, and/or liabilities arising from or resulting from said medical treatment. By signing this form, I agree that all information is accurate and current, that all important information is listed on this form, and to the best of my knowledge, my child can participate safely in the Program. I acknowledge that my failure to disclose relevant information may harm my child and/or others during this program. I agree to notify the program of any changes in the above information as soon as possible.
Signature of Parent/Guardian:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy

Entrance Questionnaire
Participant Name:

First NameLast Name
Date:

MonthDayYear
mm-dd-yyyy
Goals, Motivation, Purpose

Student is intentional about being in college
1. What does your future look like after graduating from high school?
2. What inspires you?
Personal

Student shows interest and personal reflection
3. What are some areas that you feel you need improvement on?
4. Tell me about some of your strengths (academic, non-academic, hobbies, etc.)
5. What are you involved in at school? What would you like to join? (sports, clubs, etc.)
6. How have you been a leader or displayed leadership? Please provide a specific example.
7. Do you have a job?
Academic Progress

Student shows interest in academic progress
7. When your grades are slipping, what steps do you take to raise them?
8. In the classroom what type of student are you?
9. Have you ever been on a college visit? What schools would you like to visit?
10. Have you taken Dual Enrollment classes? If you have not, would you like to?
11. Have you taken the ACT/SAT? If not have you begun preparing for it?
12. Have you met your Community Service Requirements?
Program Specific

Student shows commitment to program
13. What would you like to get out of this program as a participant?
14. What is your t-shirt size?
Class Specific Questions
Freshman: What are you most looking forward to in high school?
Sophomore: What advice would you give to an incoming freshman?
Junior: What is one thing that you have accomplished in high school that you are proud of?
Senior: If you could change one things about your high school, what would it be?
Commitment

Student shows commitment to program
15. Why would you want to make this commitment and what would be a likely challenge for you?
16. Are you available for the summer?

Model Release
Participant Name:*

First NameLast Name
Participant Phone Number:*
(999)999-9999
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Phone Number:*
(999)999-9999
Parent Email:*
example@example.com
Model Release Agreement

I hereby agree that the District Board of Trustees of Palm Beach State College (the "College"), and those acting pursuant to its authority, shall have the right to record my participation, appearance, likeness and voice on videotape, audiotape, photograph, digital, electronic or in any other medium and I hereby unconditionally and irrevocably consent to the College's use of such materials for any legal purpose the College deems appropriate for the benefit of the College, including commercial and advertising purpose also, I hereby forever waive () any right to require payment from the College for the use of these materials by it or those acting pursuant to the College authority and (i) the right to object to the use of such materials for any purpose permitted by this Consent and Release, including, without limitation, the license or sale of such materials by the College and those acting pursuant to its authority who publish, print, display, exhibit, distribute or otherwise publicly use any such materials for any legal purposes

I understand the foregoing consent and release grants the College the right to edit; crop, retouch, or otherwise reasonably alter such materials, at its discretion, and, at its option, to reveal my name and identity in such materials or by descriptive text or commentary.

I understand and agree that any intellectual property rights associated with such materials are the sole property of the College.

Furthermore, I agree that this release shall be construed in accordance with the laws of the State of Florida and if any term or provision of this release shall be held illegal, unenforceable, or in conflict with any law governing this release, the validity or enforce-ability of the remaining portions shall not in any way be affected or impaired thereby.
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy

Parental Transportation Consent
Participant Name:*

First NameLast Name
Parent/Guardian Name:*

First NameLast Name
Transporatation Release Agreement

If accepted into the Upward Bound Glades Region Program, 1 give my child {main_name} permission to attend and participate in Upward Bound Glades Region at Palm Beach State College, which may include field trips, tutorial sessions, and physical acitivies.

I also understand and acknowledge that transportation for field trips, academic enrichment sessions, conferences, and other activities will be by bus, van, train, airplane, or private car. In consideration of these activities provided to my child, hereby release the Upward Bound Program, Paim Beach State College, and its employees from any claims for injury or damage arising out of my child's participation, particularly for injuries, or damage resulting from my child not following and adhering to the rules and policies of the Program.

I give the Upward Bound Glades Region Program permission to provide the necessary transportation to my child in order for them to participate fully in any related Upward Bound activities during the Academic or Summer Component.
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy

Student Contact Sheet
Student Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name(s):*

First NameLast Name
Please check your relation to the student:*

Parent(s)Grandparent(s)Legal Guardian(s)Other
Student's Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Primary Home Phone:
(999)999-9999
Student's Primary Cell Phone:*
(999)999-9999
Student's Primary Email Address*
example@example.com
1st Contact Parent/Guardian is

First NameLast Name
Relation:
Home Phone:
(999)999-9999
Cell Phone:
(999)999-9999
Work Phone:
(999)999-9999
Email:
example@example.com
** Used for staying updated and other communication**
2nd Contact Parent/Guardian is

First NameLast Name
Relation:
Home Phone:
(999)999-9999
Cell Phone:
(999)999-9999
Work Phone:
(999)999-9999
Email:
example@example.com
** Used for staying updated and other communication**

Commitment to Success
TRIO Upward Bound Glades Region Program commits the following to your success:
- A supportive and inclusive environment.
- Access to academic advisor/admin who can assist in academic planning, financial literacy, college prep, and general academic guidance
- Access to a variety of workshops throughout the academic year and opportunities to give back to the community
- Academic progress reports that are reviewed and updated throughout the year
- An educational and fun fun 6 week summer program that includes college visits, cultural activities, and enrichment activities
As an active participant of TRIO Upward Bound Glades Region, l will:
- Participate in 2 meetings per month with an academic advisor/admin
- Attend UBG sponsored activities throughout the academic year such as college visits, workshops, Financial Literacy activities, etc.
- Notify a UBG staff member if 1 cannot make it to a meeting/appointment as soon as possible.
- Keep accurate contact information (phone, email, address) on file.
- Check, read, and respond to your student emails, GroupMe, and text messages.
TRIO UBG Participation Clauses:
- To be compliant with federal grant regulations, TRIO UBG reserves the right to drop students who do not attend and meet UB requirements.
- Students have the right to withdraw from the TRIO UB program at any time by their own accord pending completion of an exit survey and feedback form.
Student Name*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Name*

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Upward Bound Program

Health Insurance Information

Medical Information

Goals, Motivation, Purpose

Personal

Academic Progress

Program Specific

Class Specific Questions

Commitment