List up to three careers that interest you:

All information is required and will be kept strictly confidential and secure. Any incomplete information will delay the process of your request. For more information, call 814-865-2320

BIOLOGICAL / ADOPTIVE PARENT information is required.
* DO NOT INCLUDE stepparent information

FOSTER- OR STEP-PARENT / GUARDIAN * Complete only if the student does not live with the biological or adoptive parents.

STUDENT CITIZENSHIP

INFORMATION ON HOUSEHOLD AND INCOME

By signing below, I testify that all the information provided is correct to the best of my knowledge.

Student Consent

As a Penn State Upward Bound Programs participant, I understand that I must meet the following requirements:

• Maintain an academic average of 2.5 and move to the next grade level.
• Inform UBP staff of any academic difficulties I may have that may prevent you from maintaining an average of 2.5.
• Enroll in college preparatory courses while in high school.
• Participate in UBP activities scheduled in the academic year. This includes traveling to Penn State, meeting at school, and completing online assignments as needed.
• Attend the 6-week summer program, at least once before grade 12.
• Enroll in college for the fall after high school graduation.

I authorize Penn State Upward Bound Programs to have access to all academic records for my current school, as well as those records from any schools I have attended in the past. I understand that these materials will be used to identify qualified UBP participants and to monitor academic progress. I also grant continuous access to all my academic records if I leave the program before graduating from high school. 

Upon graduation from high school, I authorize the release of postsecondary enrollment information to Penn State Upward Bound staff. This includes, but is not limited to, admission applications, enrollment information, class schedules, and financial aid documents such as FAFSA, student aid reports, and award letters. 

I understand that these records are confidential and will only be used to comply with United States Department of Education regulations and program evaluation. I understand that my postsecondary educational efforts will continue to be monitored for at least six years after my date of departure from the Upward Bound Programs.

Parent / Guardian Consent

Participation Consent: I give consent for my student to participate in the activities of Upward Bound Programs of Penn State University, both educational and social, which may include, but are not limited to, academic classes, field trips, testing, tutorial sessions, individual and group academic support and/or virtual programming as required by the program. I understand that my student is required to participate in activities scheduled throughout the academic year, which include traveling to Penn State via UBP sponsored transportation, meetings at their school, and completing assignments online as needed.

Information Release: I authorize and permit the release of all of my student’s academic records from their current school, as well as any schools attended in the past or in the future, to Upward Bound Programs. This includes, but is not limited, to, grades, transcripts, individual education and standardized test scores (PSSA, KEYSTONE SAT, etc), and proof of high school and/ or college graduation for the purpose of compiling and reporting data to the United States Department of Education, Office of Post-Secondary Education annually.

I understand that the United States Department of Education requires Upward Bound Programs at Penn State University to report on my academic progress through my high school years, graduation from college, and/or for at least four years after my expected high school graduation. I understand that these materials will be used to identify qualified UBP participants and monitor academic progress. I also grant continued access to all my student’s academic records if he or she leaves the program prior to graduating from high school. This complies with the Family Educational Rights and Privacy Act of 1974 (Public Law 93 - 80, Section 513(b)(4)(a). I understand these records are confidential and will only be used to meet the U.S. Department of Education’s regulations and program evaluation.

Liability Release: I agree that neither Penn State University nor its employees (which includes, but is not limited to, the Director, Assistant Director, Counselors, instructors, tutors, and student workers) acting within the scope of the Upward Bound Programs shall be held liable for any accident or injury while my son/daughter is participating in a UB sponsored field trip or activity (including the 6-week summer program), either at the destination or in traveling to or from said destination.

Publicity Consent: My student’s name and/or image may appear in printed or webpage-based public relations materials produced by the Penn State Upward Bound Program for the purposes of recruitment, as well as positive promotion of the UB program. Personally identifying sensitive information (ie. social security numbers) will never be released to the public. Please contact us at 814-865-2320 if you wish to have your child excluded from such items.

Please provide Upward Bound Programs with the names and contact information of a MATH, ENGLISH, and SCIENCE teacher that you have, or have had in the recent past, who can tell us about your academic strengths and potential.if you do not have their email address, we will contact them.