Upward Bound Application

Only completed applications with accompanying counselor recommendation forms will receive consideration for the Upward Bound program. Applicants will receive a response by mail and telephone call. Those who meet the program requirements will be invited in for a meeting with the Upward Bound team.

The information on the Hughes Elite Scholars Upward Bound application is used to determine whether students are eligible for the Upward Bound program. Admission into the program is based upon eligibility, need, and readiness for the program. We may not admit every student who is eligible, depending on the number of applications received.

1. Student Information Form

First Name

Last Name

Middle Name

Sex (M/F)

Male Female

Date of Birth

Age

Email Address (Put an email you regularly check)

Student School ID#

Home Home Number

Student Cell Phone Number

Street Address

City

State

Zip

Student Citizen Status

U.S. Citizen U.S. Permanent Resident

Green Card

Other Not a U.S. Citizen or U.S. Permanent Resident

If "Other" was selected, please explain:

Are you Hispanic or Latino?

No Yes

What is your race? Choose all that apply

American Indian or Alaskan Native

Asian

African American or Black

White or Caucasian

Native Hawaiian or Pacific Islander

Other

If "Other" was selected above, please explain:

Current Grade

8 9 10 11 12

Expected Graduation Year

Do you plan to attend college after graduating from high school?

Yes No Not sure

How did you hear about the Upward Bound Program?

Do you plan to work this school year or next summer?

No Yes

If yes, when?

During school year During the summer Both school year and summer

If yes, estimated hours per week:

By signing below, the student verifies that all of the information for Hughes Elite Scholars Inc. Upward Bound Program is, to the best of their knowledge, factual and that no information was presented with any intent to defraud.

Student Signature

Date

2. Student Essay Form

As part of the selection process, the Upward Bound Program asks each student to tell us in writing about yourself and your interests, why you want to participate in UB, and what reasons you have for attending college or another post-secondary training program after high school. Be specific and tell us in at least 200-500 words as much about yourself as possible. Not only will this writing sample be used for selection, but it will also be used to determine how we can help you develop your writing skills.

Upload Student Essay

Add file

Please upload a file

3. Parent/Guardian Form

Student Applicant Information

Child's Name

High School

Natural or Adoptive Parent/Legal Guardian 1

First Name

Last Name

Parent/Guardian Email

Sex (M/F)

Option 1 Option 2

Occupation

Job Title

Has this person earned a (4 year) bachelor's degree from an accredited institution?

Yes No

Parent's Cell Number

Parent's Home Number

Natural or Adoptive Parent/Legal Guardian 2

First Name

Last Name

Parent/Guardian Email

Sex (M/F)

Option 1 Option 2

Occupation

Job Title

Has this person earned a (4 year) bachelor's degree from an accredited institution?

Yes No

Parent's Cell Number

Parent's Home Number

Household Income Information

With whom does the applicant live?

Parent 1 Parent 2 Both Parent 1 & Parent 2

Total number of people in the household (including those away in college)

Total annual gross income for all parent(s)/guardian(s) living with the student. An income statement form must be signed by the parent/guardian if the two income fields are not filled in. A program staff will send the form to the parent/guardian.

Total taxable income (adjusted gross income-deductions and exemptions):

This is featured on line 10 of the 1040 form (2021 or 2022)

At school, your child receives

Full cost meals Reduced cost meals Free meals

Primary language spoken at home

English Other

Of "Other" was selected, please enter the primary language spoken at home:

By signing below, the parent/guardian verifies that all of the information for Hughes Elite Scholars Inc. Upward Bound Program is, to the best of their knowledge, factual and that no information was presented with any intent to defraud.

Parent/Guardian Signature

Date

4. Internet/Photo Release Form

My signature below indicates I am providing consent for my son/daughter to utilize the Internet for educational purposes in accordance with the Acceptable Use Policy of Hughes Elite Scholars, Inc. Additionally, I agree and consent to allow the photographs, and/or audio/video recordings taken or created during the Upward Bound activities to be placed on the web and in public information materials. I further agree to allow the UB program to release, for educational purposes, photographs, and video recordings, with or without audio, of program activities and projects including my child and/ or likeness. I agree that the use herein may be without compensation to me or my child. I hereby waive any right to inspect or approve the finished electronic, photograph, or printed matter that may be used in conjunction with them now or in the future. I am expressly releasing Hughes Elite Scholars, Inc, its agents, employees, licensees and assigns from any and all claims which I may have for invasion of my child’s privacy, right of publicity, defamation, copyright infringement, or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast, or exhibition of such recordings.

Student Signature

Date

Parent or Guardian's Signature

Date

Executive Director's Signature

Date

5. Liability Waiver Form

LIABILITY WAIVER, ASSUMPTION OF THE RISK, AND INDEMNIFICATION AGREEMENT FOR HUGHES ELITE SCHOLARS PROGRAM

In consideration for being allowed by Hughes Elite Scholars Inc., to participate in the Upward Bound Program the undersigned custodial parent/guardian hereby agrees as follows:

I do hereby affirm and acknowledge that my child is participating in the Program for his/her own personal benefit and have been fully informed of the inherent hazards and risk to them associated with this activity including property damage, falls, contact with other participants, motor vehicle accidents, sprains, and other personal injuries. I accept and assume responsibility for all risks, known and unknown, involved to my child and their property in the aforementioned activity, and I voluntarily authorize my child’s participation in reliance upon my own judgment and knowledge of my child’s experience and capabilities.

I understand that the determination of my child’s ability to participate in the Program should be made by my child’s physician if necessary. I understand that I need the approval of a physician if I am uncertain as to his/her physical fitness for the rigors of this Program. I understand that I may be required to seek approval from a physician if there is a health safety question relative to my child’s condition before being allowed to participate in the Program. In addition, I give permission to any doctor, hospital, or other medical facilities to release confidential to the treating physician(s) for my child any information they may have concerning his/her medical condition and their professional contact with him/her for treatment purposes. I hereby grant my permission for such diagnostic, therapeutic, and operative procedures as deemed necessary for a child. A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any

medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.

I shall indemnify and hold harmless Hughes Elite Scholars Inc., and its trustees, officers, employees and agents from any liability, losses, costs, damages, claims or causes of action of any kind or nature whatsoever, and expenses, including attorney’s fees, arising from, or proximately caused by my child’s participation in this program, including any travel. I further agree to accept and assume for myself, my assigns, executors, and heirs any and all such risks and losses that may occur.

I have read the Program’s rules and regulations and hereby accept the regulations of the Program described therein. I understand that the Program has the authority to establish and enforce other regulations in addition to these.

I understand that this is a legal document that is binding on me, my heirs, and assigns and on those who may claim by or through me. I am eighteen years of age or older, have the full capacity to enter into this agreement and do so voluntarily.

Parent or Guardian's Signature

Date Signed

Name of Child

School

6. Health Statement Form

Please list any and all physical conditions that your student may have which might affect or be affected by participation in this program in which the Upward Bound Staff should know.

Present medical problems or conditions:

Medication taken regularly

Allergies (including allergies to medications):

Medical release for:

Student's First Name

Student's Middle Name

Student's Last Name

I do hereby grant permission to the Executive Director of Upward Bound, or the Executive Director’s authorized representative, to furnish first aid as my child (named above) may require, as well as to seek medical attention through the nearest medical facilities such as those provided on campus and those medical facilities available when students are on field trips and other authorized activities.

This permission is conditioned upon the understanding that, in the event of serious illness or the need of hospitalization and/or major surgery, the Executive Director from providing such emergency treatment as any be necessary for the Best Interest of the life of my child. A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.

Parent/Guardian's Signature

Date Signed

In case of emergency, notify:

Address

Cell Phone

Home Phone

Work Phone

7. Student Assessment Form

Career Choices/Planning

Please select one:

I am undecided about my choice of career and would like assistance/information about careers I already know my career choice

If you already know your career choice, please enter it:

If you would like information on certain careers, please enter them:

Tutoring/Academic Assistance

What is your Grade Point Average?

If you would like a tutor to assist you, please enter the subjects you need help with:

College/University Choice

I would like assistance in choosing a college to attend after high school graduation.

Yes No Not sure

I would like information on the following colleges:

My college choice is:

I plan on obtaining:

Associate's degree

Bachelor's degree

Master's degree

Doctorate or professional degree

None of the above

Not sure at this time

Financial Assistance

Please check all that apply:

I would like financial aid assistance and help applying for the FAFSA.

I would like information about the financial aid programs available.

I would like information about scholarships, and assistance applying for scholarships.

None of the above.

Not sure at this time.

Counseling

Please check all that apply:

I would like personal counseling.

I would like academic counseling.

I need to talk to improve my confidence, self-esteem, and/or social skills.

I feel that I need additional guidance and support.

Not sure at this time.

Thank you for completing the first step in our Upward Bound application. A program staff will send the Counselor's Recommendation form to your school counselor. Please follow up with your counselor to ensure the Counselor's Recommendation form was completed and sent to the Hughes Elite Scholars. Inc Upward Bound staff member.

A student's application is considered fully completed once the Counselor's Recommendation form is submitted. Once an application is fully completed, an Upward Bound program staff will contact with you. If you have questions or concerns, please call the office 704-549-0919.

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