Fill - Free fillable Sacred Heart UNIVERSITY UPWARD BOUND PROGRAM APPLICATION 2019-2020 (Sacred Heart University) PDF form

Sacred Heart

UNIVERSITY

UPWARD BOUND PROGRAM APPLICATION 2019-2020

(TYPE OR PRINT ALL OF THE INFORMATION REQUESTED)

1. Name: _________________________________________________________________

2. Street Address: ___________________________________________________________

City: _______________

State: _______

Zip Code: ___________

3. Student Email Address: _________________________________________

4. Home Phone #: ___________________Student Cell # ________________

5. Date of Birth: _____________________________________

6. Gender: (Check one)

Male ___ Female ___

7. Are you a U.S. Citizen:

(check one) Yes ___ No ___

*If NO: Are you a permanent resident/Do you have a Green card:

(check one) Yes ___ No ___

*(a copy is required)

*Date applied for Visa: ____________ Date Visa expires: ______________

*Race/Ethnic Background: (check one)

___ African American ___ Native American ___ Native Alaskan

___ Asian American

___ Pacific Islander ___ Hispanic/Latino

___ Caucasian

___ Other (specify) ____________

For #9 & 10: If you do not live with both of your parents, please only list the parent you do live with.

9. Mother’s Name: ____________________________

Cell Phone #: __________________

Place of Employment: ________________________

Work Phone #: _________________

Email Address:_____________________________

10. Father’s Name: _____________________________

Cell Phone #: __________________

Place of Employment: ________________________

Work Phone #: _________________

Email Address: _____________________________

11. School Attending: (check one)

Bassick ____

Bridge Academy ____

Bridgeport Military Academy ____

Central ____

Fairchild Wheeler: Bio Tech ____ Aerospace ______ IT _____

Harding _______ Other – Please Name:_______________________

12. Current Grade Level: (check one) 8

___ 9

___ 10

___ 11

___ 12

th ____

13. High School Guidance Counselor: ________________

HR#: _________

_____________________________________________________________________

_____________________________________

14. Are you currently enrolled in any other Trio Programs: Talent Search GEAR UP Other__________

15. Student selection is based on many factors, one is academic need. In 50 words or less, describe

why you need help from the Upward Bound program. This is your opportunity to tell us how this

program will benefit you. Openings are limited so please make sure your answer will grab our

attention. Be sincere. (TO BE FILLED OUT BY STUDENT)

For Parents only:

In order to provide the best possible service to your child, we need to know if they have any

documented learning disabilities. If yes, please provide a copy of their IEP.

Briefly describe:

Summer Component:

As stated, to provide an environment where you child can succeed and thrive, we will ask you to sign a

release allowing us to inform teachers of your child’s disability. This will allow the teacher to modify

their syllabus and work requirements for your child.

I hereby authorize the Upward Bound Program to inform summer teachers of my child’s

disability.

Parent Signature/Date

If you have any questions regarding this application, please contact one of the staff members below.

Carylanne Rice-Ehalt, Executive Director Emma Sanchez, Assistant Director

(203) 371-7864 (203) 365-7658

Please visit our website: www.sacredheart.edu/upwardbound

________________________________ _______________________________

UPWARD BOUND PROGRAM

STUDENT TUTORING CONTRACT

I ______________________________ and my parent ___________________________

Student’s Printed Name Parent’s Printed Name

understand that the Upward Bound staff may recommend tutoring for me if they feel I am not

performing my best in a subject. I also understand that when they recommend tutoring the first time,

I may accept or decline; however, if my grade(s) do not improve and a second recommendation is made

I MUST ACCEPT, sign up for tutoring and attend all scheduled sessions.

Student’s Signature/Date Parent’s Signature/Date

5151 PARK AVENUE, FAIRFIELD, CONNECTICUT 06825-1000

TEL (203) 371-7866

● FAX (203) 371-7759

_____________________________________________________________________

________________________________ _______________________

UPWARD BOUND PROGRAM

INFORMATION & AUTHORIZATION FOR EMERGENCY MEDICAL CARE

(TYPE OR PRINT ALL INFORMATION REQUESTED BELOW)

Student’s Nam ____ _____________

Last Middle

_____________________

First

e: _______________

Permanent Home Address: __________________________________________________

City State Zip Code

Home Telephone Number: ___________________________________________________

Please note any allergies or other health concerns that staff should be aware of as well as any dietary

requirements. (Inhalers, pain medication, etc. PLEASE NOTE: We are not permitted to

dispense ANY type of pain reliever such as Tylenol, Advil, etc. Students must bring their own.

Does your son/daughter have medical insurance? (check one) Yes ___ No ___

Name of Insurance Company: ________________________________________________

Policy Number: __________________________________________________________

Name of Policy Holder: _____________________________________________________

I hereby authorize the Upward Bound staff to handle any emergency care of my son/daughter

(named above) resulting from an accident or illness that occurs during a program activity. I

agree to pay all medical expenses incurred which are not covered by my policy (primary) or

the Upward Bound insurance policy (secondary). I understand that my son/daughter will be

taken to a hospital in the event that emergency treatment is required and that the Upward

Bound staff will notify me immediately.

Signature of Parent/Guardian Date

5151 PARK AVENUE, FAIRFIELD, CONNECTICUT 06825-1000

TEL (203) 371-7866

● FAX (203) 371-7759

UPWARD BOUND PROGRAM

AUTHORIZATION FOR RELEASE OF INFORMATION

I ______________________________________________________

Full Name of Parent/Guardian (please print)

hereby give permission for_____________________________________

Name of High School (please print)

to release my child’s _________________________________________

Full Name of Child (please print)

Upward Bound is a federally funded program and as such, we must meet federal requirements

in order to continue to secure our funding. Funding is contingent upon submitting an annual

performance report on all current students and prior participants.

As the crux of Upward Bound is academic based, we must provide this information on every

child and therefore rely on academic records.

Academic records include but are not limited to official High School transcripts, as well as

information obtained from Power School, (the Bridgeport Board of Education (SIS) Student

Information System), or whatever student portal your child’s school utilizes.

IMPORTANT: Please be assured that this information is entered into a confidential

database and all paperwork is destroyed.

This release form remains valid for a period of five years even if your child has left the

program due to federal regulations, which require grantees (Sacred Heart University’s

Upward Bound Program) to provide information on participants who have left the program.

Username: _________________________

Password: _________________________

______________________________

Signature of Parent/Guardian

________________

Date

5151 PARK AVENUE, FAIRFIELD, CONNECTICUT 06825-1000

TEL (203) 371-7866

● FAX (203) 371-775

PARENT PERMISSION FORM

FOR PICTURE RELEASE

CHILD’S NAME_____________________________________________

PHOTOGRAPHS/VIDEOTAPES:

Occasionally the Upward Bound staff at Sacred Heart University may wish to take photographs or

videotapes of the students in the program. Your permission is needed to allow these photographs to

be displayed in print, audiovisual, or web based media. More often than not, the pictures are put up

on the programs Facebook page. I further understand that no compensation will be provided for use

of any of the photographs or videos.

Please check one:

• Yes my child may be photographed or videotaped ___

• No my child may not be photographed or videotaped ___

PARENT’S NAME________________________________________

PARENT’S SIGNATURE____________________________________

DATE: __________________

5151 PARK AVENUE, FAIRFIELD, CONNECTICUT 06825-1000

TEL (203) 371-7866

● FAX (203) 371-775

UPWARD BOUND PROGRAM

SIX-WEEK SUMMER COMPONENT

I ______________________________ and my parent ___________________________

Student’s Printed Name Parent’s Printed Name

understand that the most important component of Upward Bound occurs during the six week intense

session in the summer, usually the week after school is over. By signing this form, we are acknowledging

that we do not have any vacation planned during this time period nor will we plan anything after we

sign.

_______________________________

Student’s Signature/Date

______________________________

Parent’s Signature/Date

5151 PARK AVENUE, FAIRFIELD, CONNECTICUT 06825-1000

TEL (203) 371-7866 ● FAX (203) 371-775

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Sacred Heart UNIVERSITY UPWARD BOUND PROGRAM APPLICATION 2019-2020 (Sacred Heart University)

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