Student Application

Numbers only. No dashes or spaces.
Please only use numbers. Include area code and phone number.
Gmail preferred
    
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, employer, 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:
My student has the permission to participate in events and activities supervised by Upward Bound (UB). Furthermore, should my student require medical attention and/or care while participating in UB, I give my consent to medical examination and necessary treatment, including drugs, x-rays, and surgery as may be deemed necessary by the attending physician. This consent shall remain effective so long as my student is a participant in UB. Should an emergency arise, staff will attempt to reach me and be guided by my wishes. In the event that I cannot be contacted, the attending physician has my consent to act as medical judgment may indicate.
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.

Please read and enter your name below signifying that you agree with the following statement:

I/We give permission for my/our student to participate in the Upward Bound (UB) program at Cal Poly and allow UB to access any school or financial records of my student to determine: eligibility for the program; status and progress in middle, secondary and post-secondary education; and eligibility for financial aid. In addition, I give my permission for my child's name, photograph, work and/or statements to be used by UB for promotional, publicity or instructional purposes in print and/or electronic formats. 

All information provided in this application is accurate to the best of my knowledge.

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