New Student Application

    STUDENT APPLICANT INFORMATION

    (To be completed by the student):

    Upload Copy of Social Security ID
    Gender MaleFemale
    Citizenship:
    Ethnic Background:

    PARENT APPLICATION

    (To be completed by the Parent/Guardian):

    Household and Income Verification Information:

    Has either parent received a 4-year degree from a college or university?
    If Yes, Please specify:

    *Please note that Taxable Income is usually lower than Adjustable Gross Income which is located at the bottom of the first page of most tax forms. Annual Taxable Income can be found on second page of most tax forms. If your income level is “0” please enter “0”.

    2017 TRIO Low-Income Levels: The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

    Annual Taxable Income

    For family units with more than eight members, add the following amount for each additional family member: $6,270 for the 48 contiguous state, the District of Columbia and outlying jurisdictions.

    PARENTAL RELEASE FOR STUDENT TRAVEL

    I authorize Near North Development Corporation to provide transportation for my child to program activities. I hereby release the Educational Talent Search and Upward Bound Program from any responsibility for any criminal act of malice, vandalism, theft and any other unlawful behavior during his/her trips sponsored by Near North Development Corporation.

    In return for my son/daughter’s attendance to program activities, I fully and forever RELEASE, WAIVE AND DISCHARGE, AND COVENANT NOT TO SUE, Near North Development Corporation (including, but not limited to, its trustee, employees, students acting as employee and representatives), from and for any and all demands, claims, actions, suits, damages, losses, liabilities, costs and expenses (including, but not limited to, court costs and attorney’s fees), from any causes whatsoever (including, but not limited to, travel delays, property damage and loss, bodily injuries, sickness, disease and death), directly or in directly arising in connection with my son/daughter’s participation in the NNDC ETS and UB Programs.
    If for any reason my son/daughter engages in an unlawful act and is detained by the local police while traveling with the NNDC ETS and UB programs, an attempt will be made to notify me. In the event that I can or cannot be reached I understand that the program staff will leave my son/daughter in the custody of the local police and I assume full responsibility to make arrangements on his/her behalf.

    EMERGENCY MEDICAL AUTHORIZATION / HISTORY FORM

    Through the year we take our students on a variety of field trips. Therefore, it is necessary that we have an accurate medical history in the event that emergency treatment is required. All information is confidential. Any student without a completed and signed Medical Information Form will not be allowed to participate in field trips

    MARK ALL ITEMS “YES” OR “NO”. PLEASE PROVIDE DETAILS WHEN ANSWER IS”YES”!

    Please list any details to items marked “yes” that have not been explained above. List any current or past medical conditions that may require treatment.

    MEDIA and SOCIAL MEDIA RELEASE FORM

    There are times when we photograph or video events in the program as part of activities and special projects. Videotaping and photographs provide a visual record of activities happening during the ETS and UB Programs held with Near North Development Corporation. We may also video or photograph the youth and group leaders (or speakers) engaged in learning activities from time to time for our own professional development, Near North Development Corporation reports or website use.

    Additionally, there may be occasions for which a photographer from the media is present to take picture of the youth. Frequently, such photographs include youth as part of a group and are printed in the media without the youth’s name. Before publishing any pictures or video, we are asking for your permission to do so. Please indicate your preference regarding this issue by checking one under each heading below.

    Video/Media Permission


    give my permission for my child to appear in media releases authorized by Near North Development Corporation. Further, I do give my permission for my child to be included in any videotaped events/activities. I understand that these videotapes may be aired over local access cable.

    Internet Photo-Use Permission


    give my permission for photos of my child to be posted on the Internet through the Organization’s web pages. These photos will be put on web pages designed to show activities that are happening within the programs and/or with student recognition. If a student’s name is used, we will post first names only.

    Social Media Permission


    give my permission for my child to be a member of the Organization’s social media pages. The social media pages are designed to show activities that are happening within the programs and/or with student recognition.

    RELEASE OF ACADEMIC SCHOOL RECORDS

    I authorize the Educational Talent Search and Upward Bound I and II Programs of Near North Development Corporation to access and/or receive copies of my academic transcripts, student schedules, grade reports, report cards, and any other academic information and test results necessary to complete the program’s application process.

    Will you be able to attend weekly and mandatory after school tutoring sessions?

    Will you be able to attend the Six-Week Summer Enrichment Institute with NNDC each summer?

    STUDENT’S STATEMENT

    Is there anything that may prevent you from going to and succeeding in college?
    Why do you want to be in the Near North Development Corporation Upward Bound Program?
    What are two goals you would like to accomplish while being a Near North Development Corporation Upward Bound participant? Why are these goals important to you?
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