Application Information: (please print)
Please list your brother(s) and/or sister(s) with their ages and current grade level:
UB / UBMS Program Eligibility Documentation
In the case of divorce, please list the parent who claims the student on their federal tax form as a tax deduction.
Use your last year's 1040, 1040-EZ, or 1040A tax form to complete this section. If you did not file a tax return, please complete the Untaxed Income section below.
I understand that the information I have provided here is for the use of UB/UBMS and partner agencies only and will remain confidential. I relieve the program of any responsibility for any accidents, illnesse, or injuries, which may result fom participatio and allow them to take pictures for program documention and promotion. Be it known that I, as parent/guardian of the student, hereby grant unto any medical doctor or hospital my consent and authorization to provide such aid, treatment, or care to said student as, in judgment of the doctor or hospital, may be required on an emergency basis in the event said student should be injured or stricken ill while participating in an UB/UBMS sponsored event or field trip.
I agree that as a participant in the Upward Bound / Upward Bound Math & Science program at Patrick Henry Community College I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been informed of the general nature of the risks involved in this activity, including, but not limited to slips and falls, needle pricks, and contracting diseases such as COVID-19, also known as the coronavirus disease.
COVID-19 is a pandemic of respiratory disease that spreads from person-to-person. COVID-19 can cause mild to severe illness; most severe illness occurs in older adults. Nevertheless, people of all ages with severe chronic medical conditions including, but not limited to, heart disease, lung disease, and diabetes are also at a higher risk of developing serious COVID-19 illness. Healthcare workers caring for patients with COVID-19 have a higher risk of exposure and I understand that the Clinical Facility may have patients recovering from COVID-19. At this time, there is no vaccine to protect against COVID-19 and no medications approved to treat it.
Symptoms of COVID-19 include fever, cough, and shortness of breath. Reported illnesses range from very mild (including some with no reported symptoms) to severe, including death. If I feel sick, I agree not to go to the Clinical Facility and that I will stay home, except to receive medical attention if necessary. I also agree to take all necessary precautions recommended by the Centers for Disease Control and Prevention, including but not limited to washing my hands thoroughly and often, avoiding gatherings of ten or more people, covering my mouth and nose if I cough or sneeze, and avoiding public transportation, ride-sharing, or taxis.
I agree to abide by any and all specific requests by the College and the Clinical Facility for my safety or the safety of others, as well as any and all of the College’s and the Clinical Facility’s rules and policies applicable to all activities related to this program. I understand that the College and the Clinical Facility reserve the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others.
In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby agree that I am responsible for any resulting personal injury or illness which may occur as a result of my participation or arising out of my participation in this program. I understand that this Assumption of Risk form will remain in affect during any of my subsequent visits and program-related activities, unless a specific revocation of this document is filed in writing with Clinical Facility, at which time my visits to or participation in the program will cease.
I have read and understand the risks involved in participating in a clinical education program at a clinical facility during this pandemic. I understand that I have the option to postpone any clinical placement without academic penalty. I also understand that I must complete the requisite number of clinical hours to complete the health professional academic program in which I am enrolled. If I choose to postpone any clinical placement, I understand that my progression within the health professional academic program will be delayed.
I understand that the information I have provided here is for the use of UB/UBMS and partner agencies only and will remain confidential. I relieve the program of any responsibility for any accidents, illnesse, or injuries, which may result fom participatio and allow them to take pictures for program documention and promotion. Be it known that I, as parent/guardian of the student, hereby grant unto any medi cal doctor or hospital my consent and authorization to provide such aid, treatment, or care to said student as, in judgment of the doctor or hospital, may be required on an emergency basis in the event said student should be injured or stricken ill while participating in an UB/UBMS sponsored event or field trip.
The student named above is participating in the Patrick Henry Community College Upward Bound/Upward Bound Math Science Program. I understand that UB/UBMS staff is required by federal regulations to track participant grades, SOL scores, academic progress throughout high school (including a final transcript) and access to college enrollment and academic standing (for six years post secondary graduation I give permission for this information to be released to the PHCC UB/UBMS staff.