Central College Upward Bound II

New Student Application for 2020-2021

APPLICANT INFORMATION
Last Name *
Middle name or Initial *
First Name *
Address *
City *
State *
Zip *
Social Security Number *
Birthdate (mm/dd/yyyy) *
Place of Birth *
Gender
Student Is:
US Citizen
Becoming a Citizen or Permanent Resident
Highschool *
Current Grade *
Projected Date of H.S. Graduation (month/year) *
Student Cell Phone Number *
Student Email *
T-shirt Size *
Are you currently a participant in:
Science Bound
GEAR UP
ETS
Upward Bound - Simpson
Upward Bound - DMACC
Ethnicity:
Do you identify as Hispanic/Latino?  1=Yes  2=No
Ethnic (Hispanic) *
Please also choose which racial groups you most identify with (even if you also identify as Hispanic or Latino).   1=Yes  2=No
American Indian/Alaskan Native *
Asian *
Black or African American *
White *
Native Hawaiian or Other Pacific Islander *
Has the student ever been convicted of a felony? *
Has the student ever been convicted of any offense that places you on the Sex Offender Registry in Iowa or any other state? *
Do you have any summer plans/activities that would cause you to miss more than one class day during the 2021 summer session June 6-July 2? If so, explain. *

STATEMENT OF APPLICATION

I hereby apply for admission to the Central College Upward Bound (CCUB) program. I certify all information provided herein is true and accurate to the best of my knowledge. I understand that knowingly providing inaccurate or incomplete information may result in expulsion from the program.

I understand CCUB is an academic program designed to help students develop the knowledge, skills, and attitudes necessary for the pursuit of education beyond high school. I understand if admitted, I will be expected to participate fully in BOTH the six-week summer residential program and the academic year program of activities organized for program participants. CCUB activities in the summer and academic year may include academic instruction, workshops, field trips (within or outside Iowa), cultural events, tutoring, conferences, social events, community service, or physical activities. Failure to participate at acceptable levels may result in the loss of stipends, suspension, or expulsion from the program. I have been informed that additional benefits to program participation include:

 
 
  • Room, board, transportation, and will be eligible to earn up to $120.00 in stipends during the summer session, June 6-July 2.
  • Up to $40.00 per month stipend during academic year, transportation to workshops, field trips, college visits, cultural events, and tutoring as needed during the academic year. (Stipend amounts are dependent on academic performance, behavior, and/or program participation.)

I agree to abide by all CCUB policies and rules as established to create a safe, welcoming, and positive learning environment.

I understand and agree to abide by the following CCUB policy regarding the use of tobacco, alcohol, and/or illegal drugs: CCUB participants, regardless of age, may not possess, use, or distribute to others tobacco products, alcohol, or illegal drugs. Students violating this policy will be subject to suspension or expulsion from the program.
Signature of Student *
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I agree to the terms included.
Signature of Parent or Legal Guardian *
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INCOME VERIFICATION

The United States Department of Education requires each UB program to select two-thirds of program participants from families whose taxable income is at or below federal income guidelines that are set annually by the Department.  The information requested in this form documents participant eligibility and will be kept strictly confidential.
COMPLETE THE FOLLOWING SECTIONS-  A(optional) , B, & C:
SECTION A:
Please upload a copy of Page 1 and Page 2 of your completed 2019 federal tax form 1040
SECTION B:
Family Income/Self Reported

Using your 2019 federal tax form please indicate the number of exemptions, which is equal to your number of dependents plus person filing the tax form plus spouse (if filing a joint return) as well as your taxable income, which is the amount on Line 11b from form 1040.

If you submitted a copy of your tax forms in Section A, please enter NA for the next two questions.
Number of Exemptions *
2019 Taxable Income *
I submitted my tax forms in section A, therefore I entered NA in this section.. Please answer YES or NO *
SECTION C:
Financial Assistance
Check all that apply:
Applicant resides in a foster home
Applicant does not reside with a natural or adoptive parent
Food Stamps Case
Food Stamps Case #
FIP Case #
I have completed this section or none of the above apply to the student. Please answer YES or NA. *

For Roosevelt / Lincoln / Pella / Oskaloosa students only:

Please check if your student qualifies for:
Free (not Reduced) School Lunch

STUDENT HOUSEHOLD INFORMATION
Who has legal custody of the applicant? *
How many people live in the house the student resides? *
What language is most frequently spoken in the household? *
How many children under the age of 21 live in your household (include students who live at home during school vacation)? *
What is the address where the applicant resides most (or at least 50%) of the time? *
1. Who is the 1st Head of Household (adult responsible for the applicant's financial support and care) at the above address?
Name (Last, First, MI):
Who is this person to the student? *
Does this person claim the student as a dependent on their federal tax returns? YES or NO *
Mark the highest level of education completed by the 1st head of household: *
2. Who is the 2nd Head of Household (adult responsible for the applicant's financial support and care) at the above address?
Name (Last, First, MI): *
Who is this person to the student? *
Does this person claim the student as a dependent on their federal tax returns? YES or NO *
Mark the highest level of education completed by the 2nd head of household: *
3. Does the student applicant have a natural/adoptive parent with whom the applicant does NOT reside most of the time? *
Does this parent provide at least 50% financial support for the applicant?
Does this parent have full or partial legal custody of the applicant?
If you answered YES to either of the previous 2 questions please provide the parent's:
Name (Last, First, MI):
Address:
Mark the highest level of education this parent has completed:

CONSENT TO PHOTOGRAPH UB PARTICIPANTS
UB regularly photographs or makes digital/video recordings of UB participants while involved in program activities.  These photographs and video tapes may be used for program newsletters or publications, informational brochures/presentations, informational or recruiting video presentations, and program web pages.  Identifying information (student name, high school, and/or grade level) will be used for internal publications only and not for release to the public.
I give permission for CCUB to photograpgh or videotape son/daughter for the purposes described above and in accordance with the guidelines contained therein. *
Parent/Legal Guardian SIgnature - Consent to Photo *
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Student SIgnature- Consent to Photo *
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Date Signed *
Student Name *

UPWARD BOUND PERMISSION TO RELEASE SECONDARY SCHOOL RECORDS

I consent to the release of my school records including, but not limited to, demographic data/contact information, enrollment/school transfer information, school attendance, transcripts, grades and report cards, test scores, recommendations, disciplinary records, and other relevant information regarding my school performance to the CCUB Program. I understand information shared under the terms of this agreement shall be kept confidential and used for the following purposes:

  1. Determining admission to the UB program.
  2. Developing an individualized plan and providing academic advising to support my growth, interpersonal development, and preparation for success in accessing and completing postsecondary education.
  3. To provide data to the U.S. Department of Education and to Central College for the sole purpose of assessing the effectiveness of UB in providing services to students.

I understand my records will be kept in a confidential file and will be used for the reporting purposes described above.

 

This release shall remain in effect from the date indicated below until 12 months following the date of my graduation from high school. I understand that if I am not admitted to the program, this release shall be immediately null and void. I understand I may revoke this release at any time by submitting to CCUB a dated, signed statement denying the release of secondary school records.

SIgnature of Student *
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PARENT/LEGAL GUARDIAN PERMISSION:

The school my son/daughter attends has my permission to release his/her school records to the CCUB Program to be maintained and utilized as described above.
Signature of Parent/Legal Guardian *
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Date signed *

RELEASE OF INFORMATION: ACADEMIC STANDING/ENROLLMENT & GRADUATION STATUS

I recognize CCUB provides assistance to students preparing for and applying to postsecondary education programs and institutions. I understand the U.S. Department of Education and Central College have an interest in assessing the effectiveness of CCUB in providing these services. I therefore consent to the release of information regarding my enrollment, financial aid, academic standing, and graduation status from my postsecondary institution, the National Student Clearinghouse, and/or state data system to CCUB. I understand this information will be held in a confidential file and will be used only for the reporting purposes described above.

This release shall remain in effect for seven twelve-month periods (7 years) beyond the date of my planned graduation from high school. I understand that if I am not admitted to the program, this release shall be immediately null and void. I understand I may revoke this release at any time by submitting to CCUB a dated written statement denying the release of the above information.
Student Name: *
Planned Date-H.S. Graduation ( Month/Year) *
Student Signature: *
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I reviewed and give my consent to the release of information as described above regarding the enrollment, financial aid, academic standing, and graduation status of my son/daughter from his/her postsecondary institution, the National Student Clearinghouse, and/or state longitudinal data system to CCUB. I understand this information will be maintained and used for the sole purposes described above.
Signature of Parent or Legal Guardian *
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Date Signed *

PERMISSION FOR PARTICIPATION, MEDICAL TREATMENT, AND LIABILITY RELEASE

This release/treatment authorization must be signed by a parent or guardian and on file in the UB office before a student may participate in program activities. 

Name of Student Participant: *

A.  Permission to participate in Central College Upward Bound (CCUB) Activities and Release of Liability

A1. Permission to participate in CCUB

My son/daughter, listed above, has my permission to participate in all activities undertaken by the CCUB program during the academic year and summer program beginning January 1, 2021 and concluding the last day of August 2021.  This includes field trips (in and out of state), events on Central College campus, and off-campus educational/cultural events.

A2. Release of Liability

In consideration of the CCUB project granting the student permission to participate in Upward Bound, I hereby assume all risks of his/her personal injury (including death) that may result from any CCUB project activity, which may include field trips, overnight camping, tutorial sessions, living in residential halls and physical activities, including, but not limited to, swimming pool activities and usage.  As parent or guardian, I do hereby release Central College, the CCUB project and their officers, employees, and agents, and all instructors and all participants in said CCUB project program from all liability, including claims, demands, causes of action and suits at law or in equity, for injury, fatal or otherwise, or for any property belonging to the student which may result from the student taking part in CCUB activities, or while in, on, upon, or traveling to and from any CCUB activity where it is being conducted.
Signature of Parent or Legal Guardian *
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Date signed *

B.  Permission for CCUB Personnel to Seek Medical Services for Program Participants

I hereby give my consent for CCUB personnel to select and secure medical services, as CCUB personnel deem prudent and necessary for the health and safety of my son/daughter while he/she is a participant in a CCUB event or residential program.  Medical services may include but are not restricted to outpatient treatment, emergency hospitalization, anesthesia, surgery, injections, and/or prescription drugs.

Please read each of the following paragraphs and mark whether the statement applies to your son/daughter.
My son/daughter is covered by a medical insurance policy. I agree to provide CCUB with evidence of medical coverage with the insurer’s name, address, and contact information. I understand that CCUB will present this information to medical service providers who treat my son or daughter at the request of CCUB personnel. I agree to assume full responsibility for the cost of treatment of my son/daughter in excess of the limits this coverage. 
This statement applies to my son/daughter *
If your son/daughter is covered by insurance, please upload a copy of their insurance card

My son/daughter is not covered by a medical insurance policy.  I understand that CCUB will provide limited coverage for the cost of treating my son/daughter for illnesses and accidents while participating in CCUB. This coverage provides up to $750 for illnesses and $2,500 for accidents occurring while engaged in program activities to the extent covered by the CCUB insurance policy. I will assume full responsibility for the cost of treatment of my son/daughter in excess of these limits.  I understand that illnesses or accidents resulting from pre-existing conditions or self-inflicted injuries are excluded from CCUB insurance coverage.  In the case of an illness or accident that is the result of a pre-existing condition or self-inflicted injury, the bill will be promptly forwarded to me for payment or submitted to my insurance carrier and I will assume full responsibility for the cost of treatment of my son/daughter.
This statement applies to my son/daughter *

I ask that billing, diagnostic and treatment information, and/or medical records related to medical services provided to my child at the request of CCUB personnel be forwarded to the insurance company contracted by CCUB to provide medical coverage for program participants and/or released to/directed to the attention of:

Director, Central College Upward Bound         Central College, 812 University Street, Pella, IA  50219

This release shall be in full force and effect throughout the period beginning January 1, 2021 and concluding August 31, 2021.
Signature of Parent or Legal Guardian *
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Date signed *

C.  In Case of Emergency, Please Contact:
1. Parent/Guardian Name *
Cell # *
Alternate Phone # *
If I am unable to be reached using the contact information above, please contact one of the following.  I give the following individuals permission to have access to medical information about my son/daughter and to make decisions regarding his/her treatment in my absence. 
2. Alternate Contact 1- Name *
Cell# *
Alternate Phone #
Relationship to student *
3. Alternate Contact 2 - Name
Cell #
Alternate Phone #
Relationship to student
Signature of Parent or Legal Guardian *
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Date signed *

HEALTH INFORMATION
Does the student applicant have any "Med Alert" conditions? *
If you answered YES, please explain
Does the student have any allergies? *
If you answered YES, please list allergies
Has the student applicant's physical activity been restricted during the past five years? *
If you answered YES, please explain
Has the student applicant had any recent illnesses, injuries or been hospitalized within the last year? *
If you answered YES, please explain
Has the student applicant received counseling for emotional, psychological, and/or life event problems? *
If you answered YES, please explain
Please check any of the following that apply to the student applicant:
Alcohol and/or drug abuse/addiction
Eating Disorder
Depression
Suicidal history or idealation
Anxiety or Stress Management
Emotional instability
Other, please explain

PARENT/LEGAL GUARDIAN INFORMATION

(To be completed by custodial parent/legal guardian)

Upward Bound regularly mails/emails program information, event information, and student progress reports to parents or legal guardians.  Each applicant may list up to two individuals to whom information should be sent.  Please complete the following so Upward Bound may send information to the appropriate individuals
1. Name *
Relationship to student:
Mother
Father
Legal Guardian
Other
Street Address *
City *
State *
Zip *
Home Phone *
Cell Phone *
Work Phone *
Email Address *
Place of Work *
Fluent/Native English Speaker *
Interpreter Required *
If you answered YES to the last question, list the language.
2. Name *
Relationship to student:
Mother
Father
Legal Guardian
Other
Street Address *
City *
State *
Zip *
Home Phone *
Cell Phone *
Contact 2 Work Phone *
Email Address *
Place of Work *
Fluent/Native English Speaker *
Interpreter Required *
If you answered YES to the last question, list the language

NO CONTACT INFORMATION

(To be completed by custodial parent/guardian)
Is there any individual who should NOT receive information about or have contact with this student? *
If YES, is there a legal restraint or no contact order in effect?
Please provide the name of individual(s) who should not receive information about or have contact with this student:
Name
Relationship to Student
Name
Relationship to Student
Signature of Parent or Legal Guardian *
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Date signed *
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