Revised by Kilgore College Upward Bound: May 2020
Kilgore College Upward Bound Program
AUTHORIZATION & RELEASE FORM
2020-2021
Academic Records Authorization
I, , as a participation of Upward Bound, understand that in order to participate in the Upward
Bound Program at Kilgore College, I must provide UB staff with a copy of my academic grade report(s) every six weeks as well
as year-end transcripts. I hereby authorize the UB staff to receive copies of my academic grade reports, transcripts, and
standardized test scores from my school so that UB staff can assist me in achieving my educational goals.
As the parent/legal guardian of the student listed above, I grant the UB Program at Kilgore College permission to obtain copies
of my child’s academic grade reports, transcripts, and standardized test scores from the school so that UB to assist in my
son/daughter achieving his/her educational goals. I also grant the UB staff my permission to speak with teachers, counselors,
and any other school administrators at my child’s school in order to obtain and exchange information as part of the services
provided by the UB Program.
Participation & Field Trip Liability Waiver
I authorize and permit my son/daughter to participate in any and all UB Program events (classes, tutoring, workshops, field
trips, meetings, events, etc.) sponsored and/or facilitated by the UB Program at Kilgore College. I also give permission for my
child to be transported between his/her high school, college campuses, and off-campus cultural visits as part of the UB
schedule of events. I agree that Kilgore College and the UB staff will not be held liable for any loss, injury, or death related to
any UB Program events. Furthermore, I agree to hold Kilgore College and its staff harmless from any claims whatsoever
occasioned in any of the situations in which I have agreed that Kilgore College shall not be held liable.
Media Publication & Internet Use Release
I hereby grant the UB Program at Kilgore College full and absolute permission and all rights to copyright, publish, display, and
use for any legal purpose all photographs and descriptive text or statements in which my child, my property, or I appear. I
hereby grant permission for my child to access networked computer services such as the Internet, World Wide Web, and
electronic mail at the computer labs of Kilgore College.
Medical Release
Is the student covered by any medical insurance? ___Yes ___No If Yes, please complete the following:
Name of Insurance Company: ________________________________ Insurance Policy Number: _________________________
Name of Family Physician: ____________________________________Office Telephone: ( ____) _________________________
Please list any student or family medical history that may be of importance to our records, including allergies and
physician prescribed medicine that student is currently taking:
Describe Allergic Reaction
As the parent/guardian of the above named student, I hereby authorize the Project Director and his/her authorized staff to furnish medical diagnostic
and/or authorize the medical and/or surgical treatment of my child as may be considered necessary or appropriate under the circumstances for the
treatment of any illness or injury of the child. The Kilgore College and its employees shall not be liable in any way for any consequences from said diagnostic,
medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise out of such diagnosis, treatment
or surgery to the extent allowed by law, except as provided for through the group medical insurance plan if the student contracted for the same prior
diagnosis, treatment or surgery. Furthermore, Kilgore College does not assume any financial or other responsibility, but wishes to provide the best
services possible in case of emergency.
______________________________________________________ ___________________________________________________
Student’s Name (Please Print)
Parent/Legal Guardian’s Signature
________________________________________ __ _______/_______/_______
Student’s Signature
Date
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
