LPRSP 24-26 Application

Liberty Partnerships Rising Stars Program (LPP)

2024-2026 Application
Student's Full Name*

First NameMiddle NameLast NameSuffix
Student's Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-BinaryOther
Race and Ethnicity (select ALL that apply)*

Black or African AmericanAmerican Indian, Native Haiwaiian or Alaskan NativeAsian or Pacific IslanderHispanic or LatinoWhite or of European Descent
School *
Student ID Number
Grade*

6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
Guidance Counselor (or individual responsible for tracking academic progress)
Sport (if applicable)
Student Email*
example@example.com
Student Cell Phone Number

Area CodePhone Number
How can we support the student? (select all that apply)*

TutoringMentoringCollege and Career ExplorationSocioemotional SupportWorkforce DevelopmentPersonal Development
Parent/Guardian Information
Parent/Guardian Full Name*

First NameLast Name
Parent/ Guardian Cell Phone Number*

Area CodePhone Number
Are you willing to accept text messages from LPRSP Staff members?*

YesNo
Parent/ Guardian Secondary Phone Number

Area CodePhone Number
Parent/Guardian Email*
example@example.com
Home Address (mailing address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship to the Student*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the Student have Medical Insurance?*

YesNo
Medical Insurance Carrier
ex: CDPHP, Blue Cross, MVP, etc.
Medical Insurance Number
Please check ONLY If you choose to DECLINE Liberty Partnerships Rising Stars Program consent to the following:*

Access to student school recordsMedical services in the event of an emergencyPhotography/VideoNone of the above
Student/ Youth Consent for Participation
I agree to full participation in the Liberty Partnerships Rising Stars Program. I commit to participate regularly, or as often as possible, attending tutoring and mentoring sessions and workshops. I understand that belonging to the Liberty Partnerships Program carries with it a commitment of time and hard work. I will fully commit to putting forth my best effort so that I can reach my fullest potential as a student.
Student Signature*

Clear
Authorization for Participation & Access to Student Records

Parental Consent for Participation
I understand that this form grants the Liberty Partnerships Program permission for the following:
- Obtaining and reviewing certain confidential educational record(s), information, or data that may be protected under State and Federal law including but not limited to the Family Educational Rights and Privacy Act and New York State Education Law2-d which includes but are not limited to report cards, transcripts, attendance records, discipline referrals and college acceptance letters.
- I (we) understand that all information obtained will remain confidential. Utilizing confidential educational record(s) helps for the planning of appropriate support services for my child/youth.
- I (we) also give permission for our child/youth to participate in program related activities. Offsite activities will require a signed permission slip.
- Our family will participate in scheduled family/guardian events including family support workshops and seminars, Family Celebrations, and Moving Up Ceremonies.
Parent/Guardian Signature*

Clear
I consent that I have read and received the Liberty Partnerships Rising Stars Program authorization form, authorizing access to student records, medical emergency response, and photography release.
Please verify that you are human*
Should be Empty:

Liberty Partnerships Rising Stars Program (LPP)

Parent/Guardian Information

Emergency Contact Information

Student/ Youth Consent for Participation

Authorization for Participation & Access to Student Records