New Student Application
Please complete this application in its entirety. All completed applications will be reviewed and eligible applicants will be contacted within 14 days regarding their status.
Today's Date
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Month
-
Day
Year
Date
Student Name
*
First Name
Last Name
Social Security Number
*
Use this format (xxx-xx-xxxx)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What school do you attend?
*
What is your current grade level?
*
7th
8th
9th (Freshmen)
10th (Sophomore)
11th (Junior)
12th (Senior)
Student ID Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Citizenship
*
United States citizen
Permanent Resident
Ethnic Background
*
African American or Black
American Indian
Asian/Pacific Islander
Hispanic
White
Other
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Parent Application
Parent 1
*
First & Last Names
Relation to Student
*
Address
Cell Phone Number
Parent 2
First & Last Names
Relation to Student
Address
Cell Phone Number
How many people (dependents) are in your household? (Size of Family Unit)
*
Household & Income Verification Information
Has either parent received a 4-year degree from college or university?
*
Yes
No
If you selected yes, please specify which parent received a 4-year degree. If you selected no, then click the N/A option
*
Mother/Guardian
Father/Guardian
N/A
Please select annual taxable income
*
$0-$18,090
$18,091-$24,360
$24,361-$30,630
$30,631-$36,900
$36,901-$43,170
$43,171+
Parent Signature
*
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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 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.
Student Signature
*
Parent Signature
*
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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 trip
Name
*
First Name
Last Name
Birthday
*
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Month
-
Day
Year
Date
Gender
*
Male
Female
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First & Last Name
Phone Number
Mark each medical condition that you are living with if applicable
*
Diabetes
Heart defects
Asthma
Convulsions/Epilepsy
Any hearing deficiencies*
Allergies (include medications, foods, insect bites, etc.)*
Currently taking medication*
Physical restrictions*
Currently under doctor's care*
None
Other
If you selected any of the medical conditions above that were starred (*), then please specify
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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 ETSand 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 for our 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 pictures 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
I 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
*
Yes
No
I 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
*
Yes
No
I 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
*
Yes
No
Student Signature
*
Parent Signature
*
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Release of Academic School Records
I authorize the Educational Talent Search and Upward Bound 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. This consent is effective for the entire duration my child is in this program.
Name
*
Student's Full Name
Student's School Name
Student Signature
*
Parent Signature
*
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