Tusculum College-Cocke-Hawkins-UB-Parent Information Form

We must have an updated copy of this form each year in order for your child to participate in Upward Bound activities. Please fill this form out to the best of your ability. If you have any questions regarding the fields on this form, please contact Catherine Pearson at capearson@tusculum.edu or 423-609-8088. Thank you!

1. Legal Name:*

First NameLast Name

Email*

example@example.com

2. Preferred Name:

3. Date of Birth:

mm-dd-yyyy

4. Age:

5. SSN:

999-99-9999

6. Student Cell Phone:

(999)999-9999

8. Name:*

First NameLast Name

9. Relationship to Student: *

10. Home Phone:

(999)999-9999

11. Cell Phone:*

(999)999-9999

12. Street Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

13. Employer:

14. Work Phone:

(999)999-9999

15. Name:

First NameLast Name

16. Relationship to Student:

17. Home Phone:

(999)999-9999

18. Cell Phone:

(999)999-9999

19. Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

20. Employer:

21. Work Phone:

(999)999-9999

22. Name: *

First NameLast Name

23. Relationship to Student: *

24. Home Phone:*

(999)999-9999

25. Cell Phone:

(999)999-9999

26. Name:

First NameLast Name

27. Relationship to Student:

28. Home Phone:

(999)999-9999

29. Cell Phone:

(999)999-9999

30. Please list the name and relation of any person(s) that are permitted to visit your child at Tusculum University.*

YesNo

32. If yes to the prior question, please list:

33. Insurance Provider: *

34. Policy Holder:*

35. Policy Number: *

YesNo

37. If yes, please explain:

YesNo

39. If yes, please list the medication and reason:

YesNo

41. If yes, please list allergy and reaction:

YesNo

43. If yes, please list allergy and reaction:

YesNo

45. If yes, please list activities:

YesNo

47. If yes, please explain:

I certify that my child has my permission to receive routine, preventative and/or emergency medical and dental care during time in attendance with Cocke-Hawkins Upward Bound. In case of emergency, I understand that my child will be taken to a hospital or clinic and I will be notified. I hereby release the TRIO Programs Director, his staff and Tusculum University for responsibility for, or legal action as a result of decisions made with regard to medical care and the treatment of my child. I further certify that I understand that my child will be subject to all rules and regulations of the Cocke-Hawkins Upward Bound program.

48. Parent/Guardian Signature

49. Date

mm-dd-yyyy

Tusculum University Cocke-Hawkins Upward Bound

Section 1: Student Information

Section 2: Parent/Guardian #1

Section 3: Parent/Guardian #2

Section 4: Emergency Contact #1 - (Someone we may contact other than parent(s)/guardian(s).)

Section 5: Emergency Contact #2 - (Someone we may contact other than parent(s)/guardian(s).)

Section 6: Health Insurance Information

Section 7: Student Health Information

Section 8: Signature