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Upward Bound Application - Parent Section

  1. COMPLETE:  This Parent Section form accompanies the Upward Bound - Student Application. Please read each question carefully and complete all sections. Deadline: 5 p.m., Friday, November 13, 2020
  2. INCOME ELIGIBILITY:  Upward Bound will collect parent tax information in the form below. As a Federal Grant Program, Upward Bound requires this information to determine student eligibility. This information is kept confidential.
  3. QUESTIONS:  If you have questions about the application process, please call our office at 660.562.1862.

Do NOT refresh the page or risk losing your progress.

* indicates required fields. If any information is unknown at this time, please enter N/A in the form field.

Step 1: Demographic Data

Applicant Information

*Student Name:

*Student Gender:








*Text messages okay?


Step 2: Parent/Guardian Data and Income Eligibility

Note, this information is necessary for determining program eligibility and is required of all families whose children are served by the Upward Bound Program. Your cooperation is needed in filling out the information completely. All information provided is kept confidential.

Natural/Adoptive Father Information

*Father's Education: (mark highest level completed)
*Does the student live with the natural/adoptive father?
*Is the natural/adoptive father deceased?





Natural/Adoptive Mother Information

*Mother's Education: (mark highest level completed)
*Does the student live with the natural/adoptive father?
*Is the natural/adoptive father deceased?





Income Eligibility

The following numbers correspond to 2019 taxable income on the federal forms. Check only one box and complete the corresponding instructions. If the student is married or has legal dependents other than a spouse (i.e. a child), use the student’s tax information. (This information is required to help determine eligibility for acceptance into Upward Bound.)

*Did you complete an Income Tax Return last year?

Please submit a copy of last year’s signed tax return to UB.NWMSU@gmail.com, which includes your 1040. If you prefer, you may fax your income tax information to 660.562.1631 in lieu of email. List all household members below.

Please send a signed statement that you did not file income taxes in 2019, which summarizes your financial situation to UB.NWMSU@gmail.com. If you prefer, you may fax your income tax information to 660.562.1631 in lieu of email. List all household members below.

(count everyone currently residing in the household)

Household Member #1


(before deductions)

(before deductions)




Household Member #2


(before deductions)

(before deductions)




Household Member #3


(before deductions)

(before deductions)




Household Member #4


(before deductions)

(before deductions)




Household Member #5


(before deductions)

(before deductions)




Household Member #6


(before deductions)

(before deductions)




Household Member #7


(before deductions)

(before deductions)




Step 3: Consent & Agreements

Consent for Medical Treatment

In case of emergency, please contact the following:

























Allergies & Dietary



Please list ALL medicines/prescriptions your child will take/is currently taking:















I understand that my child will administer his/her own medication at the prescribed dosage and time listed above. I understand that it is my child’s responsibility to take over the counter medications according to package directions.

I hereby give my permission for my child to receive any medical attention, including preventative, routine and emergency care, as deemed necessary by qualified medical personnel, in the event such treatment is necessary during the entire time the student is enrolled in Upward Bound. I also understand that neither Northwest Missouri State University nor the Upward Bound Program staff can be held responsible for accidents or injuries.

*Do you give medical consent?

Parent/Guardian Statement of Permission and Support

I hereby grant permission for my child, , to participate in the Upward Bound program at Northwest Missouri State University.

I pledge to support my child in his/her endeavors for academic success and to encourage his/her participation in the Northwest Missouri State University Upward Bound program. I understand that my child will be required to attend approximately 8 Saturday Academies and weekly tutoring at his/her high school during the academic year and the six-week residential summer component on the Northwest Missouri State University campus each year.

I hereby give the Northwest Missouri State University TRIO Upward Bound Program permission to receive copies of educational records and other materials necessary for participation in the Program. Further, permission is granted to request academic and financial aid information and records from any and all postsecondary institution is order to track college progress. I understand all of my records will be kept in confidence and in accordance with the Privacy Act of 1974.

You have our consent to release grades, test scores, and any other academic records to the Northwest Missouri State University TRIO Upward Bound Program.

*Do you give participation permission?

Media Release Form

I give permission for my son/daughter’s photo image to be used on the Northwest Missouri State University’s Upward Bound website or in other program promotional materials.

*Do you give media release permission?

Northwest Missouri State University Waiver of Liability Agreement

In consideration of the services provided by Northwest Missouri State University, its board, employees, volunteers, participants, and all other persons or entities acting in any capacity on its behalf (collectively, “UNIVERSITY”) in conjunction with the UPWARD BOUND program (“Event”), I hereby agree to release, hold harmless, covenant not to sue, and discharge UNIVERSITY, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows:

  • (“Minor”) will participate in the Event. I understand that each Academic Year, theUpward Bound program will have eight Saturday Academies involving participating in sessions on campus and traveling to othercolleges for campus visits. I understand that some of such activities will not take place on Northwest Missouri State University property.
  • I acknowledge that Minor’s participation in Upward Bound entails known and unanticipated risks, which could result in physical oremotional injury, paralysis, death, or damage to Minor, to property, or to third parties. I understand that such risks include activitiesat and away from UNIVERSITY. I understand that such risks simply cannot be eliminated.
  • I acknowledge that the unlawful possession/consumption/use/distribution of alcohol or any controlled substance, including theunauthorized possession/consumption/use/distribution of prescription medications, is strictly prohibited. I agree that any violation ofthis policy may result in Minor’s immediate removal from Upward Bound. I understand that UNIVERSITY will not store or administerprescription medication(s) for Minor. If Minor will be in possession/utilize medication(s) during Upward Bound, I hereby representthat I have explained to Minor the Event’s policy on alcohol and controlled substances. I further represent that I have discussed withMinor the proper use/administration of the medication(s), including frequency and dosages. I understand and agree that Minor issolely responsible for storing/administering any medication(s) as directed by Minor’s physician or healthcare professional.
  • I expressly agree and promise to accept and assume all of the risks associated with Minor participating in Upward Bound. Minor’sparticipation in Upward Bound is purely voluntary, and I elect to allow Minor to participate despite the risks. If Minor is injured duringUpward Bound, I hereby give my consent for UNIVERSITY to contact appropriate medical professional(s) and further consent to anymedical treatment that may be required, as determined by a medical professional. I understand that the cost of any such treatmentwill be Minor’s or my sole responsibility; UNIVERSITY will not be responsible for any cost related to such treatment in any way. Ialso understand that UNIVERSITY will not be responsible for any medical treatment that Minor receives.
  • I hereby voluntarily release, waive, covenant not to sue, and forever discharge any and all claims of negligence against UNIVERSITYthat relate in any way to any activity Minor undertakes in conjunction with Upward Bound, including transportation to, during, and fromthe Event.
  • Should UNIVERSITY, or anyone acting on its behalf, be required to incur attorney’s fees and costs to enforce this Agreement, Iagree to indemnify and hold them harmless for all such fees and costs.
  • I understand that UNIVERSITY does not maintain an insurance policy that would provide coverage if Minor is injured during theEvent or causes any injury during Upward Bound. I certify that I have adequate insurance to cover any injury or damage Minor maysuffer or cause while participating in Upward Bound, or else I agree to bear the costs of such injury or damage myself.
  • I understand that UNIVERSITY may photograph, film, and/or record (“Medium”) Minor’s participation in Upward Bound. I authorizeUNIVERSITY to use Medium and Minor’s likeness in conjunction with any UNIVERSITY marketing and/or promotional materials,including, but not limited to, social media accounts. I understand that neither Minor nor I will be compensated in any way for suchuse.

In the event that I file a lawsuit against UNIVERSITY, I agree to do so solely in the State of Missouri, and I further agree that the substantive law of Missouri shall apply without regard to conflict of law rules. I agree that if any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By checking "Yes" below, I expressly state that I have had sufficient opportunity to read this entire Agreement and agree to be bound by its terms.

I further acknowledge that this document contains a negligence waiver and indemnification provisions.

*Do you agree to the above "Waiver of Liability Agreement"?

Parent/Guardian Agreement

I understand the purpose of the Northwest Missouri State University TRIO Upward Bound Program, which is to prepare participants to successfully complete a program of postsecondary education. As part of my personal effort in this preparation, I commit to support my child’s participation in all academic year and summer components of Upward Bound. I understand that attendance is an integral part of participating. Therefore, I agree to support my child in attending and actively participating in all classes, meetings and activities sponsored by Upward Bound. I am aware that failure to comply with all rules and regulations of the TRIO Upward Bound Program could result in my child’s dismissal from the program.

*I understand and willingly commit to meeting these expectations.




By submitting this form, I certify that all the information I have typed into this form is correct and I understand that any false information (or omissions) in the contract agreement or its supporting documents will be sufficient grounds for my dismissal in the TRIO Upward Bound program. I agree to all the above statements and will fully participate in the TRIO Upward Bound program.

To retain a copy of this application for your records,
PLEASE PRINT THIS PAGE NOW!

 

    

 

Northwest Missouri State University
TRIO Upward Bound Office
Administration Building 372 - West Wing
800 University Dr.
Maryville, MO 64468

Phone: 660.562.1630
Fax: 660.562.1631
Email: UB.NWMSU@gmail.com