General Information:

Last Name: *

First Name: *

Middle Initial:

Date of Birth: *

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Home Phone:

Cell Phone: *

May we send text messages (Message and data rates may apply)?: *

Personal Email (Not School Affiliated): *

Preferred Contact Method: *

How did you hear about us? *

Demographic Info:

Gender: *

Current Age: *

Ethnicity (Check all that apply):

Native Hawaiian or Pacific Islander

American Indian/Alaskan Native

Hispanic or Latino

Black or African American

Asian

Caucasian

Citizenship:

*Eligible Non-Citizen Includes: US National; Permanent Resident of the US or Guam or the Northern Marianas Islands or the Trust Territory of Palau; Resident of the Freely Associated States – Federated States of Micronesia, or the Republic of the Marshall Islands; or a permanent US resident application pending approval from the Immigration and Naturalization Service *

Academic Info:

Current Grade Level: *

School Attended: *

If school is not listed, please specify:

Current Cumulative GPA *

Please check the math classes you have completed/passed:

Pre-Algebra

Algebra I

Algebra II

Geometry

Trig/Pre-Calc

Calculus

Last Name of School Counselor *

First Name of School Counselor

Are you a current participant in any of the following federally funded educational programs?

AVID

Early College

Educational Talent Search

Running Start

Parent Information:

*Parent/Legal Guardian who the student currently lives with and can be contacted regarding program information and/or in an emergency.

Parent/Guardian 1

Parent/Guardian 1 Name: *

Parent/Guardian 1 Relationship: *

Parent/Guardian 1 Phone: *

May we send text messages (Message and data rates may apply)?: *

Parent/Guardian 1 Email Address: *

Parent/Guardian 2

Parent/Guardian 2 Name:

Parent/Guardian 2 Relationship:

Parent/Guardian 2 Phone:

May we send text messages (Message and data rates may apply)?:

Parent/Guardian 2 Email Address:

Eligibility Information

The following information is required by the U.S. Dept. of Education to determine program eligibility. Information is confidential and will NOT be reported by individual student and/or family.

The student is an orphan, in foster care, or a ward of the court? *

The student is an emancipated minor OR has a court-appointed legal guardian? *

The student is homeless (i.e., lacks a fixed, regular/adequate nighttime residence) or at risk of becoming homeless? *

The student's current primary residence is with the following parent(s): *

Does BIRTH/ADOPTIVE MOTHER have a Bachelor's Degree? *

Please indicate the college name where your BIRTH/ADOPTIVE MOTHER earned her Bachelor's Degree:

Does BIRTH/ADOPTIVE FATHER have a Bachelor's Degree? *

Please indicate the college name where your BIRTH/ADOPTIVE FATHER earned his Bachelor's Degree:

Income Eligibility:

The student qualifies for the federal FREE lunch program? *

Total Number in Household- For the primary household where the student regularly lives, including the student AND everyone in the household who is supported by the family income: *

Which is the MOST RECENT INCOME YEAR that you filed your taxes for OR planning to file your taxes for? *

What was the family’s TAXABLE income for year? (see tax form 1040 line 10): *

Student Questionnaire:

Why are you interested in joining the TRiO Upward Bound Program at Windward Community College? *

Would your schedule allow you to attend monthly Saturday Academies from 8:30am to 1pm at Windward Community College? *

What are you plans after graduating high school?

Associate's Degree (2 years, community college)

Bachelor's Degree (4years, University)

Graduate/Professional School (ex: Master's Degree, Doctorate, Medical School)

Military

Vocational School (ex: trade, cosmetology, culinary, etc.)

Work Full-Time

Undecided

My career choice(s) and/or major for college might be (1st choice):

2nd Career/Major Choice:

Do you presently have a part-time job?

If yes, how many hours per week do you work?

Need for Services and Release/Authorization

By signing, I attest that the information reported on this form is true, correct and complete to the best of my (our) knowledge. I am also aware that the information provided must be verifiable and upon request I will provide documentation and proof of citizenship, income (i.e. tax forms, national school lunch program verification, unemployment verification, etc.), and educational status.

Need for Services:

I agree that the student plans to go to college and would like to receive College and Career planning assistance from WCC TRiO Upward Bound.

Assumption of Risk and Release:

I understand that because of the inherent dangers and risks involved with the student participating in the WCC TRiO Upward Bound activities held during and/or after school hours, as well as after the student leaves the activities, that the student should be covered during said period by a private medical and liability policy; and further understand that neither the Research Corporation of the University of Hawaii or the University of Hawaii provides insurance or otherwise indemnifies individuals with respect to injuries or other liabilities arising out of participation in the WCC TRiO Upward Bound. Therefore, in consideration of the student being permitted to participate in the program, I hereby agree to assume all risks and responsibilities surrounding the student’s participation in the WCC TRiO Upward Bound. Further, I do for myself, my heirs, executors, and administrators hereby accept full responsibility for the student’s participation and agree to indemnify, release and discharge the Research Corporation of the University of Hawaii and the University of Hawaii, its officers, employees, agents and assigns from any and all claims or actions for property damage, personal injury, and/or death arising from the student’s participation in the WCC TRiO Upward Bound or growing out of or caused by any of the student’s acts or omissions during the student’s participation in the WCC TRiO Upward Bound.

Privacy and Confidentiality:

WCC TRiO Upward Bound is federally funded by the United States Department of Education. The Privacy Act protects the personal information given to WCC TRiO Upward Bound. The U.S. Department of Education has the authority to gather such information (20USC 1231a). The requested information is required by the U.S. Dept. of Education to determine program eligibility. Information is confidential and will NOT be reported by individual student and/or family. No one may see the information unless they work with or for Windward Community College and its TRiO Upward Bound program or are specifically authorized to see it. The information is necessary to determine if your child is eligible to participate in the program and helps the U.S. Department of Education to measure his or her success. All information must be provided in order to determine eligibility and receive program services.

Consent to Release Information:

My signature serves as consent for the WCC TRiO Upward Bound to make whatever contacts necessary to obtain educational and financial information about the student, and release of such information to WCC TRiO Upward Bound. My signature also gives permission for the student’s name, photograph, image, work and/or statements to be used by WCC TRiO Upward Bound for promotional, publicity or instructional purposes. I understand that access to educational records is essential for WCC TRiO Upward Bound to serve the student’s needs, and income information is necessary in order to determine the student’s eligibility for program services. I understand that all personal information will be held in the strictest confidence.

E-Signature Agreement:

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purpose of validity, enforceability, and admissibility.

Student Signature *

Signature Type: Simple Start Over

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Signature: (Type in your full name)

I agree to the terms included.

Parent/Guardian Signature *