APPLICATION DUE DATE - April 30th, 2024

This is ONLY the parent/guardian application. The student application MUST ALSO be completed.

Application Checklist:

1. Student Application https://form.jotform.com/kearnscenter/STUDENT-upward-bound-app

2. Parent Application: (This form)

The parent/guardian application and a copy or photo of the following documents MUST ALSO be submitted for your application to be reviewed and approved here: https://form.jotform.com/232975489297983

3.    Recent Report Card or Progress Report

4.   Transcript (For students in grades 10-11)

5.    Income Verification (One of the following)

a.     Signed copy of parent/guardian’s most recent federal tax return.

b.     Verification of current public/government assistance

c.     Proof of Free Lunch Eligibility

6.  Social Security Card (Required for both U.S. citizens and permanent residents).

7. Green Card (Not Required for U.S. citizens. Required for permanent residents only).

 8. An Interview (30 minutues via Zoom or In person and parent/guardian must be present)

**You may save and complete this application later if you need. Click the save button at the bottom of the form and choose to either create an account, or have the draft of your application emailed to you by clicking on "Skip create an account." 

If you have any questions regarding the application or our program, please contact us at:

585-301-4488 

I grant permission to the University of Rochester to access and/or receive copies of my child’s cumulative folder, academic transcript(s), report card(s), Regents scores, Parent Connect account information, and/or access to any other digital or print medium that relates to the information requested by the University of Rochester from my current school or school district for the entire duration of my child’s participation in the program.

I grant permission to the University of Rochester to contact my child through direct personal and/or group electronic communications (including but not limited to cell phones, texting, email, and social media) in conjunction with the operation of the program and my child’s participation in the program.

On behalf of myself and my child, I hereby give the University of Rochester permission to take photographs and videos of my child participating in University of Rochester activities, including tutoring sessions, field trips, workshops, classes, and other events. I specifically agree that the University may use the photographs and videos in whole or in part, in color or black and white, and may publish them in any form, printed or electronic. For example, photos may be used for recruitment materials, social media posts, and website publications.

I waive any right I may have to inspect or approve the photographs or the publications in which they are included, and I agree to release the University of Rochester, its officers, trustees, employees, volunteers, and agents from any liability by virtue of the use of the photographs, regardless of any blurring, distortion, optical illusion or alteration which may occur when the photographs are taken, processed, printed or otherwise displayed. I hereby waive any right to compensation for the University’s use of photographs and videos of my child.

All social/digital/telecommunication between pre-college staff members and students will include more than one staff member to adhere to the University's policies and procedures for programs for minors and children.

I hereby grant permission to the University of Rochester to provide transportation for my child in the event of an emergency using a University or personal vehicle. 

I also grant permission for my child to be transported using University vehicles or vehicles operated by university staff to participate in field trips and program events.

I also grant permission for my child to miss or be dismissed early from school if necessary to attend such trips and/or program events. 

I am the person legally responsible for the above named individual and I authorize the following:

To obtain only the information from the Rochester City School District as noted below:

By signing below I am stating that:

I hereby authorize the disclosure of educational information between organization(s) or name of person(s) listed above and the Rochester City School District (District), in accordance with the Family Educational Rights and Privacy Act (FERPA The purpose of this disclosure is to advance the education of my student.

I understand that the information disclosed will be provided to the organization(s) or name of person(s) listed above.

I understand that I have the right to revoke and/or restrict this authorization at any time without penalty, provided that I submit a request in writing to the District’s General Counsel. Any revocation shall not apply to the extent the District has already taken action in reliance on this authorization.

I authorize the periodic, on-going disclosure of the above information. This authorization expires on August 31, 2026.

Please be sure to date this form in order for the District to process.

I hereby acknowledge that I have completed this application to the best of my abilities and that the contents of the application packet are true and accurate. I further acknowledge the following:

(1) In order for my application to be considered complete, my child will need to complete the STUDENT application. 

(2) In order for my application to be considered complete I must submit income verification and verification of my child's social security number. 

(3) I understand that providing any false information or altered records in this application will result in my ineligibility to be admitted to the program and that if discovered after my admission to the program, will result in termination from the program.

By signing my name below, I acknowledge the statements described above. I further acknowledge that all information and documents provided by me for this application are true and accurate.