UPWARD BOUND APPLICATION OF ADMISSION

Family Relations

Please list the name(s), age, and relationship of other individuals currently living in your household. Also, list grade in school or
occupation of other individuals.
Family Relations Name*

First NameLast Name
Age Relationship Grade Occupation
Family Relations Name

First NameLast Name
Age Relationship Grade Occupation
Family Relations Name

First NameLast Name
Age Relationship Grade Occupation
Family Relations Name

First NameLast Name
Age Relationship Grade Occupation
Family Relations Name

First NameLast Name
Age Relationship Grade Occupation
Number of Family Members Attending College*
Please describe any hardship or circumstances that you feel we should consider
Does your child suffer from any physical problems or disabilities that we should be aware of?
Does your child suffer from any emotional and/or psychological problems?(Be specific)
Is your child receiving medication by prescription or presently under a doctor's care? If so, please list medication.

PARTICIPATION AGREEMENT

I hereby agree to participate fully in all scheduled activities.
I will attend all required weekly activities. I will attend all scheduled tutoring and counseling sessions, as well as the
summer residential session. I will commit myself to Academic Institute of Central Carolina Upward Bound Program,
graduate from high school, complete the summer Bridge Program, and enroll into a college/university within one year
of my graduating. I will allow the college or universities I attend to provide Academic Institute of Central Carolina
Upward Bound Program with a copy of my transcripts each semester. I understand the only way in which I may be
excused from any the above is through verified sickness or extreme emergency. I give permission for my name,
photo, work or statements to be used for promotional, publicity, reporting, instructional, and verifying purposes. I
authorize contact from this agency to communicate with me via cell phone, cell phone text message, home phone, and
email as needed. I certify all information on this application is true and accurate to the best of my knowledge.
Signature*

Clear
Applicant Name *
Date*

MonthDayYear
Date
PARENTAL AGREEMENT

I have read the above requirements and agree to work with my child and
Academic Institute of Central Carolina Upward Bound staff to abide by these requirements. I have read all pages of
this application and fully understand the obligation my child/ward is assuming. I authorize Academic Institute of
Central Carolina’s Upward Bound program to obtain documents relative to my child’s education (report cards,
transcripts, test scores, progress reports, etc). I authorize Academic Institute of Central Carolina’s Upward Bound
program to obtain my child’s college admission, financial aid, and college enrollment information. I will assist my
child/ward in his/her obligation to Academic Institute of Central Carolina’s Upward Bound Program. I give
permission for my and my child’s name, photo, work or statements to be used for promotional, publicity, reporting,
instructional, and verifying purposes. I authorize contact from this agency to communicate with me via cell phone,
cell phone text message, home phone, and email as needed. I certify all information on this application is true and
accurate, including the information about family income to the best of my knowledge.
Parent(s)
Signature*

Clear
Parent Name *
Date*

MonthDayYear
Date
Should be Empty:

	Father or Male Guardian	Mother or Female Guardian
Social Security Benefits
SocialServices Payments
TANF
Veteran's Benefits
Vocational Rehabilitation
Child Support
Other(specify)