2024-2025 Mentorship Academy Upward Bound Application

2024-2025 Mentorship Academy Upward Bound Application
Mentorship Academy Advance Training Institute TRIO Programs Application

The Federal TRIO Programs (TRIO) are Federal outreach and student services programs designed to identify and provide services for individuals from disadvantaged backgrounds. TRIO includes eight programs targeted to serve and assist low-income scholars, first-generation scholars, and scholars with disabilities to progress through the academic pipeline from middle school to post-baccalaureate programs. TRIO also includes a training program for directors and staff of TRIO projects.

Our TRIO Programs are recognized as a superior system that prepares students for:
- Successful completion of secondary education;
- Admission into a post-secondary institution;
- Retention and completion of post-secondary education;
- Preparation for successful matriculation to a post-baccalaureate program.
The programs identify students who show potential for success and provide encouragement, support, and assistance.
1. Student's Name (First and Last)*
2. Student's Personal Email (Non-School Email)*
example@example.com
Student T-Shirt Size (Adult Sizes)*

SmallMediumLargeX-Large2X-LargeOther
3. Confirm Student's Personal Email*
example@example.com
Student's Date Of Birth*

MonthDayYear
Date
5. Student's Cell Phone #*
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Age*
Sex*

FemaleMaleNon Binary
Are you a U. S. Citizen?*

YesNo
Are you a Permanent Resident? (Non-US Citizen)*

YesNo
Alien Registration Number (type N/A if not applicable)*
Veteran*

YesNo
Ethnic Origin*

American Indian/Alaskan NativeAsian/Pacific IslanderBlack(Non-Hispanic)HispanicWhite (Non-Hispanic)
Current Grade Level*

Freshman (9th)Sophomore (10th)Junior (11th)Senior (12th)
Are you currently in Middle or High School?*

Middle SchoolHigh School
Current School Name*
Incoming School Name*
Current GPA (On a 4.0 scale)*
Who do you live with*

Both ParentsParent & Step-parentMotherFatherGrandparentsFoster ParentLegal GuardianOther
Education plans after high school*

4-year college2-year collegeVocational SchoolOther
Please check the assistance you need.

Career choices/planningCollege admissions/requirementsFinancial AidACT/PSAT/SATVocational ChoicesStudy SkillsCollege/University ChoicesTutoringScholarshipsLibrary Usage SkillsObtaining a High School Diploma/GEDColleges/Schools for students with special needsApplication for College/University/VOTECHI would like to explore careers in the STEM (Science, Technology, Engineering and Math) fieldsI have an interest in pursuing a career in the STEM (Science, Technology, Engineering and Math) fieldI would like to learn more about financial economic literacy, financial aid, and scholarshipsOther
How did you learn about this program?*

UB ClientIndividual (friend, acquaintance, ETC.)RadioTVAgencyNewspaperBrochureOrientationCareer FairWorkshopOther
Are you currently participating in any other TRIO programs such as Educational Talent Search, Upward Bound Math/Science, Gear-up?*

YesNo
Do you participate in any other extracurricular activities?*

YesNo
Have you ever thought about dropping out of school?*

YesNo
How often do you meet with your middle or high school counselor?*
Have you decided on what college you would like to attend?*

YesNo
Have you attempted to contact the college of your choice for information?*

YesNo
Do you know the correct high school classes to take to prepare for college?*

YesNo
Do you need a college application or SAT/ACT fee waiver?*

YesNo
Do you need help with study skills?*

YesNo
Do you need help with applying for college?*

YesNo
Do you need help with applying for scholarships?*

YesNo
Parent/Legal Guardian 1- First/Last name*
Parent/Legal Guardian Cell Phone #*
Parent/Legal Guardian Email Address*
Highest Education Attained by Parent/Guardian 1*

Some High SchoolHigh School DiplomaGEDSome CollegeAssociate's DegreeBachelor's DegreeGraduate/Professional Degree
Parent/Legal Guardian 2- First/Last name
Parent/Legal Guardian Cell Phone #
Parent/Legal Guardian Email
Highest Education Attained by Parent/Guardian 2

Some High SchoolHigh School DiplomaGEDSome CollegeAssociate's DegreeBachelor's DegreeGraduate/Professional Degree
Number of Members in Household*
Total taxable income (adjusted gross income-deductions and exemptions): This is featured on line 10 of the 1040 form (2020 or 2021)*
Total annual gross income for all parent(s)/guardian(s) living with the student*
Indicate untaxed income or benefits received:*

Social SecuritySSIVeteran's BenefitsPublic AssistanceTANFVocational RehabiliationOther
Parent's Name*

First NameLast Name
I certify that all financial information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.*

Clear
Parent Signature
Recommendations- Counselor/Teacher name (First/Last name)*
Counselor/Teacher Email*
example@example.com
Confirm Counselor/Teacher Email*
example@example.com
Liability Waiver Form

LIABILITY WAIVER, ASSUMPTION OF THE RISK, AND INDEMNIFICATION AGREEMENT FOR THE MENTORSHIP ACADEMY UPWARD BOUND PROGRAM

In consideration for being allowed by Mentorship Academy, to participate in the Upward Bound Program the undersigned custodial parent/guardian hereby agrees as follows:

I do hereby affirm and acknowledge that my child is participating in the Program for his/her own personal benefit and have been fully informed of the inherent hazards and risk to them associated with this activity including property damage, falls, contact with other participants, motor vehicle accidents, sprains, and other personal injuries. I accept and assume responsibility for all risks, known and unknown, involved to my child and their property in the aforementioned activity, and I voluntarily authorize my child’s participation in reliance upon my own judgment and knowledge of my child’s experience and capabilities.

I understand that the determination of my child’s ability to participate in the Program should be made by my child’s physician if necessary. I understand that I need the approval of a physician if I am uncertain as to his/her physical fitness for the rigors of this Program. I understand that I may be required to seek approval from a physician if there is a health safety question relative to my child’s condition before being allowed to participate in the Program. In addition, I give permission to any doctor, hospital, or other medical facilities to release confidential to the treating physician(s) for my child any information they may have concerning his/her medical condition and their professional contact with him/her for treatment purposes. I hereby grant my permission for such diagnostic, therapeutic, and operative procedures as deemed necessary for a child. A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.

I shall indemnify and hold harmless Mentorship Academy, and its trustees, officers, employees and agents from any liability, losses, costs, damages, claims or causes of action of any kind or nature whatsoever, and expenses, including attorney’s fees, arising from, or proximately caused by my child’s participation in this program, including any travel. I further agree to accept and assume for myself, my assigns, executors, and heirs any and all such risks and losses that may occur.

I have read the Program’s rules and regulations and hereby accept the regulations of the Program described therein. I understand that the Program has the authority to establish and enforce other regulations in addition to these.

I understand that this is a legal document that is binding on me, my heirs, and assigns and on those who may claim by or through me. I am eighteen years of age or older, have the full capacity to enter into this agreement and do so voluntarily.
Student's Name*

First NameLast Name
Parent/Guardian's Name*

First NameLast Name
Parent or Guardian's Signature *

Clear
Date*

MonthDayYear
Date
Signature and Authorization

I agree that all the information provided is true to the best of my knowledge. I also understand that any false information I have provided may result in the denial of my application and/or my immediate dismissal from the program. I understand that if I enroll in any Mentorship Academy TRIO Program, I must participate in activities designed to achieve my academic goals and promote my holistic development.
I certify that all information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.*

I Certify
Authorization to Release Information:

I authorize Mentorship Academy TRIO Programs personnel to obtain copies of my child's transcripts, grade reports and test scores, or any other information necessary to determine eligibility for services. I permit the TRIO Program Staff to release confidential information to scholarships, post-baccalaureate, or external programs for educational planning purposes.
I authorize Mentorship Academy TRIO Programs personnel to obtain copies of my child's transcripts, grade reports and test scores, or any other information necessary to determine eligibility for services. I permit the TRIO Program Staff to release confidential information to scholarships, post-baccalaureate, or external programs for educational planning purposes.*

I authorize
Privacy Act:

I understand that the information will be kept in confidence and will not be revealed to anyone except Mentorship Academy TRIO personnel in accordance with the Family Educational Rights and Privacy Act.
I have read and understand the Privacy Act. I understand that the information will be kept in confidence and will not be revealed to anyone except Mentorship Academy TRIO personnel in accordance with the Family Educational Rights and Privacy Act.*

I authorize
Student's Name*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Health Form

AUTHORIZATIONS:

(Parent or legal guardian MUST sign if under 18 years of age)

I hereby accept financial responsibility for the expense of health care services and I authorize the medical providers of Mentorship Academy Student Health Services and their agents or consultants, including emergency medical technicians, area hospitals or other treatment facilities, to perform diagnostic and treatment procedures, on the below named student, which in their judgment may become necessary while he/she attends Mentorship Academy events.

I have no expectation for Mentorship Academy to pay medical expenses for the student should he/she need treatment outside of Student Health Services.

I agree to absolve and hold harmless Mentorship Academy in making medical decisions for the student.

I understand that every effort will be made to notify the parent or legal guardian once permission is obtained from the student in the event of a major illness or injury.

I understand that the parent or guardian may not necessarily receive notification prior to treatment.
Medical release for: Childs Full Name *
Parent Signature*

Clear
Date*

MonthDayYear
Date
In case of emergency, notify*
Emergency Contact Cell Phone #*
I do hereby grant permission to the Director of Upward Bound, or the Director’s authorized representative and staff, to furnish first aid as my child (named above) may require, as well as to seek medical attention through the nearest medical facilities such as those provided on campus and those medical facilities available when students are on field trips and other authorized activities.

This permission is conditioned upon the understanding that, in the event of serious illness or the need of hospitalization and/or major surgery, the Director from providing such emergency treatment as any be necessary for the best interest of the life of my child.

A photocopy of this permission is to be considered valid as the original.

I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.
Student's Name*

First NameLast Name
Student's Name

First NameLast Name
Parent's Name*

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
Date
Student Assessment Form
Career Choices/Planning. Please select one:*

I am undecided about my choice of career and would like assistance/information about careersI already know my career choice
I plan on obtaining:*

Associate's degreeBachelor's degreeMaster's degreeDoctorate or professional degreeNone of the aboveNot sure at this time
Please check the assistance you need*

Career choices/planningCollege admissions/requirementsFinancial AidACT/PSAT/SATVocational SchoolStudy SkillsCollege/University ChoicesTutoringScholarshipsLibrary Usage SkillsObtaining a High School Diploma/GEDColleges/Schools for students with special needsApplication for College/University/VOTECHOther
Do you need help applying for Financial Aid/FASFA?*

YesNo
Financial Assistance- Please check all that apply:*

I would like financial aid assistance and help applying for the FAFSA.I would like information about the financial aid programs available.I would like information about scholarships, and assistance applying for scholarships.None of the above.Not sure at this time.
Counseling- Please check all that apply:*

I would like personal counseling.I would like academic counseling.I need to talk to improve my confidence, self-esteem, and/or social skills.I feel that I need additional guidance and support.Not sure at this time.
Do you need tutoring?*

YesNo
I certify that all information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.
Upload Passport Style Photo*

Cancelof
Student's Name*

First NameLast Name
Student Signature that you certify*

Clear
Parent's Name*

First NameLast Name
Parent Signature that you certify*

Clear
Should be Empty:

2024-2025 Mentorship Academy Upward Bound Application

Signature and Authorization

Authorization to Release Information:

Privacy Act:

Student Assessment Form

I certify that all information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.