A photocopy of this record release form should be accepted as an original and the date signed has no bearing to the date that West Virginia State University Upward Bound program staff request the information.

The principle purpose for collecting this information is to administer program services, including tracking and evaluating participant’s academic progress.  The information collected on this form will be retained in the program files and may be released to Department of Education officials in the performance of official duties.  In accordance with the Privacy Act of 1974 (Public Law No. 93-57, 5 U.S.C. 552A), you are hereby notified that the Department of Education is authorized to collect information to implement the Upward Bound program under Title IV of the Higher Education Act of 1965, as amended (Pub Law 102-325, sec3 402C).  All information is handled in a confidential manner as protected by law.

Please write an essay telling why you want to be selected for the Upward Bound program at West Virginia State University. In this essay please tell us about:

1. Your educational and career goals after high school.

2. Any problems that may keep you from achieving these goals.

3. Why should you be selected for the TRIO Upward Bound program?

This information is necessary to ensure that the applicant meets the criteria for admission to Upward Bound as established by the U.S. Department of Education. All information on this application is handled in a confidential manner as protected by law.

Medical Authorization Acknowledgement & Agreement

This completed form will be photocopied for out of state trips and other activities when the parent/legal guardian is not present. I understand that while all reasonable efforts will be made to provide a safe environment, certain risks are involved. In consideration for the opportunity to participate in the activity, I understand the state of West Virginia, West Virginia State Univerisy, it's Board of Governors, officers, employees, agents, and volunteers are not liable in case of accidental injury or illness. I hereby further understand that in case of serious injury or illness, I will be notified. If it is not possible to contact me, I hereby give permission for emergency treatment or surgery as the attending physician recommends.

• In consideration for being accepted by West Virginia State University for participation in the Pre-College Upward Bound program, I (we), being 21 years of age or older, do for myself (ourselves)(and on behalf of my child) do hereby release, forever discharge, and agree to hold harmless West Virginia State University, West Virginia State University staff, administrators, and Board of Governors thereof from any and all liability, claims or demands for personal injury, sickness, or death, as well as, property damage and expenses of any nature whatsoever  incurred by the undersigned and the child  while said child is participating in the above described program.

• Furthermore, I (we) on behalf of my (our) child hereby assume all risk of personal injury, sickness, death, damage, and expense as a reult of participation in recreation and work activities involved there in.

• Further, authorization and permission is hereby given to said program to furnish any necessary transportation, food, and lodging for participant.

• The undersigned further herby agrees to hold harmless and idemnify said university, its administrators, and employees for any liability sustained by said initiative as the result of negligent, willful, or intentional acts of said participant, including expenses incurred attendant hereto.

• Further, should it be necessary for the participant to return home due to disciplinary action or otherwise, I (we) hereby assume all transportation costs.

• I (we), the parent(s) or legal guardian(s) of this participant, heby grant my (our) permission for him/her to participate fully in the West Virginia State University Upward Bound program.