Student Application

Mailing Address (like P.O. Box)
Please only use numbers. Include area code and phone number.
You may upload a photo or PDF of the document.

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png bmp tif pict pdf doc docx xls xlsx.
This may be from a teacher, counselor, or coach.
You may take a photo or PDF of the document as well.

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png tif pict psd txt pdf doc docx xls xlsx.
Parent/Guardian 1 Information
Please only use numbers. Include area code and phone number.
Parent/Guardian 2 Information
Please only use numbers.
Household Information
    
Medical/Emergency Information
Please only use numbers. Include area code and phone number.
Please only use numbers. Include area code and phone number.
Please list details regarding medications that student is taking, and any other current or past medical conditions that may require treatment. List/describe any physical restrictions:
I hereby authorize the staff members of the Upward Bound Program to seek and authorize medical treatment for my son/daughter in the event of an emergency. If an emergency arises requiring a major surgical procedure, the University will attempt to reach me and be guided by my wishes, but if I cannot be reached I authorize the attending physician to proceed as deemed advisable.
I agree to waive all claims against the Upward Bound Program, California State University, Cal Poly Corporation, and the Foundation that may result from my child’s participation in Upward Bound, either on a field trip, during the summer residential program, during a Saturday session, or in any other capacity.

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