Upward Bound Parent Application English [2024-2025]

Upward Bound & Upward Bound Math/Science Program Application

Parent/Guardian Application
PLEASE NOTE: This is only the PARENT/GUARDIAN part of the application and you must answer each question in order for your application to be reviewed. Contact Us at urupwardbound@gmail.com if you have any questions.
APPLICATION DUE DATE

MonthDayYear
Date
CHILD'S INFORMATION
Name:*

Childs First NameChilds Last Name
High School:*
Child's High School
Child's 890 ID Number:*
Street Address:*
Apt/Unit:
Zip Code:*
Does your child have Limited English Proficiency (LEP)?:*

YesNo
Does your child have an Individualized Educational Plan (IEP)?:*

YesNo
FAMILY INFORMATION SECTION
All federally funded programs must comply with federal regulations; we must collect this information to verify student eligibility.
PARENT/GUARDIAN 1 INFORMATION:
Parent/Guardian 1 Name:*

ParentGuardian 1 First NameParentGuardian 1 Last Name
Parent/Guardian 1 Phone #:*
Phone Type:
Parent/Guardian 1 Email:*
example@example.com
Does parent/guardian 1 live with the student applicant?:*
Parent/Guardian 1 relationship to student (Mother father sibling etc)?:*
PARENT/GUARDIAN 2 INFORMATION
Parent/Guardian 2 Name:

ParentGuardian 2 First NameParentGuardian 2 Last Name
Parent/Guardian 2 Phone #:
Phone Type:
Parent/Guardian 2 Email:
example@example.com
Does parent/guardian 2 live with the student applicant?:
Parent/Guardian 2 relationship to student:
ELIGIBILITY INFORMATION
Does either parent/guardian have a bachelor's degree (4-year degree):*
How many people are in your household?:*
ONLY individuals living in the household including yourself.
Do you receive any of the benefits listed below? (Please check all that apply):*

Medicaid or CHIP (Child Health Insurance Program)SNAP (Supplemental Nutrition Assistance Program)HEAP (Home Energy Assistance Program)SSI (Supplemental Security Income)TANF (Temporary Assistance for Needy Families)Free LunchNone of the above
Please Provide your taxable Income (This figure can be found on your IRS 1040 Tax Return Box 15):
Is your child a U.S. Citizen?:*

YesNo
Is your child a Permanent Resident?:*

YesNo
In order for your child's application to be complete, you must submit copies or photos of a document for verification. Are you able to upload or submit the following with this application?*

YesNo
Proof of Citizenship or Permanent Resident Status (Choose One):

Copy/Photo of Student Social Security CardCopy/Photo of Permanent Resident/Green Card
Income Verification (Choose One):

Most recent federal income tax return (IRS 1040)Welfare benefit statementSocial Security benefit statementBenefits verification letter from a social service agencyVeteran administration benefit statementUnemployment benefit/award statement
Rochester City School District University of Rochester Pre-College Programs (Upward Bound/Talent Search/College Prep Center) Authorization for Disclosure of Educational Information Parental Consent Form
Student Name:*
Date of Birth:*
Rochester City School District ID:*
Phone Number:*
School:*
Grade:*
Relationship to Student:*

ParentLegal Guardian
If Legal Guardian, please specify:
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, 2030. Please be sure to date this form in order for the District to process.
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Parent/Guardian Printed Name:*
Date:*

MonthDayYear
Date
Witness Signature (Anyone other than yourself):
Signature

Clear
Date:

MonthDayYear
Date
CERTIFICATION SECTION
RELEASE OF SCHOOL RECORDS
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 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.

YesNo
ParentGuardians Signature

Clear
PHOTO RELEASE
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.

YesNo
ParentGuardians Signature

Clear
SOCIAL/DIGITAL/TELECOMUNICATION DISCLAIMER
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.
SOCIAL/DIGITAL/TELECOMUNICATION MEDIA RELEASE
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.

YesNo
ParentGuardians Signature

Clear
TRANSPORTATION RELEASE
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.

YesNo
ParentGuardians Signature

Clear
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.

YesNo
ParentGuardians Signature

Clear
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.

YesNo
ParentGuardians Signature

Clear
ACKNOWLEDGEMENT CONSENT
I hereby acknowledge that I have completed this application to the best of my abilities and that the contents of the application 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 and submit 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 child's ineligibility to be admitted to the program and that, if discovered after my child's 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.
ParentGuardian Signature*

Clear
Date*

MonthDayYear
Date
Updated: 08/2024 Reviewed by: Richard Crummins, UR Legal Counsel
Should be Empty:

Upward Bound & Upward Bound Math/Science Program Application

CHILD'S INFORMATION

FAMILY INFORMATION SECTION

PARENT/GUARDIAN 1 INFORMATION:

PARENT/GUARDIAN 2 INFORMATION

ELIGIBILITY INFORMATION

Rochester City School District University of Rochester Pre-College Programs (Upward Bound/Talent Search/College Prep Center) Authorization for Disclosure of Educational Information Parental Consent Form

CERTIFICATION SECTION

RELEASE OF SCHOOL RECORDS

PHOTO RELEASE

SOCIAL/DIGITAL/TELECOMUNICATION DISCLAIMER

SOCIAL/DIGITAL/TELECOMUNICATION MEDIA RELEASE

TRANSPORTATION RELEASE

ACKNOWLEDGEMENT CONSENT