Student Application

Student First Name: *

Middle Initial

Last Name: *

Gender: *

I am a (select one): *

Permanent Residency Number: *

Date of Birth: *

Month

Day

Year

City: *

State: *

ZIP Code: *

Phone: *

Please only use numbers. Include area code and phone number.

Current School: *

Current Grade: *

Next year, I will attend (Please select one): *

Other School Name

Student Email (not school-issued): *

Gmail preferred

Race (select one or more): *

American Indian or Alaska Native	Black or African American	White	Native Hawaiian or Other Pacific Islander	Hispanic or Latino/a
Asian

Disconnected Youth (select any that apply to you):

Foster Care Youth

Homeless

Parents are Incarcerated

Are you a participant of Educational Talent Search (ETS)? *

Yes

Are you a participant of the Early Academic Outreach Program (EAOP)? *

Yes

Are you a participant of AVID? *

Yes

Please attach a recent progress report/report card. *

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.

Also include a letter of recommendation: *

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.

Do you plan on attending college? *

What obstacles do you think could keep you from attending college? *

Please tell us about you educational plans and your plans for the future: *

Why do you want to join Upward Bound? *

Do you have relatives who have participated in Upward Bound? Please list their names: *

Are you willing to commit to consistently participating in the workshops/events and completing all assignments that are required of Upward Bound participants? *

Parent/Guardian 1 Information

First Name of Parent/Guardian #1: *

Last Name of Parent/Guardian #1: *

Relation to Student

Phone: *

Please only use numbers. Include area code and phone number.

Email:

Education Level (Select One): *

Less than High School

High School

Some College

4 year degree or more

Parent/Guardian 2 Information

First Name of Parent/Guardian #2:

Last Name of Parent/Guardian #2:

Relation to Student

Phone:

Please only use numbers.

Email:

Education Level (Select One):

Less than High School

High School

Some College

4 year degree or more

Household Information

Medical/Emergency Information

First Parent or Guardian to Contact Immediately in Case of Emergency: *

Other Contact First Name:

Other Contact Last Name:

Phone Number:

Please only use numbers. Include area code and phone number.

Alternate Parent or Guardian to Contact in Case First is Unavailable

Other Contact First Name:

Other Contact Last Name:

Phone Number: *

Please only use numbers. Include area code and phone number.

Policy Holder's Name: *

Policy Number: *

Insurance Company Name: *

Group Number:

Insurance Company Address:

Insurance Company Phone Number:

Medical History of Student: *

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:

Authorization for Medical Treatment *

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.

Yes

Liability Waiver: *

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.

Yes

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.

Parent/Guardian Name *

Student Name *

Leave this field blank

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Upward Bound Student Application

Student Academic Services (SAS)

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