NJIT Upward Bound for English Language Learners (UBELL) Program Application 2022-2023

THIS APPLICATION IS FOR NEW STUDENTS ONLY WHO HAVE NOT BEEN ENROLLED IN THE PROGRAM. In order to complete and submit this application you must attend to one of the following target schools:

High Schools: Barringer & East Side High School & Central High School (ESL/ ELL Students)

Section I: Student Information/ Sección I: Informacción del estudiante

Note: Please use your last and first name as indicated on your school report card.

What is your Last Name? Cuál es tu apellido? *

What is your First Name? Cuál es tu primer nombre? *

What is your Middle Name? Cuál es tu segundo nombre?

What is your Date of Birth? Cuál es tu fecha de nacimiento? *

I.e.: June 30, 1985 or 6/30/1985 or 6/30/85

What is your home address? Cuál es tu dirección? *

Example: 218 Central Avenue, Apt. 3200

In what City, State and Zip Code do you live? En que ciudad, estado y códijo postal vives? *

Example: Newark, NJ 07102

Gender/ Sexo *

Race/ Raza *

Please check which school in the Newark School District do you attend. Que escuela en el districto de Newark estas asistiendo ahora? *

Barringer High School

East Side High School

Other:

What is your Current Grade Level? Cuál es tu grado actual? *

If it is during the Summer months (July and August), last grade completed by June.

Enrollment in this program requires a Social Security Number, Report Card, Income Verification, and Center For Pre College Programs (CPCP) Medical Form. *

Social Security Number is "Mandatory" in order to participate in this program. Do you have a Social Security Number?

Are you a U.S. Citizen? Eres ciudadano Americano? *

If not, do you have a Green Card? Si es No, tienes residencia

WAIVED NOW DUE TO COVID/ NO SON NECESARIA AHORA POR COVID -Unofficial Standardized Test Scores/ Resultados de pruebas estandarizadas *

Be prepared to provide copy of your Standardized Test Scores to the UBELL Director.Esté preparado para proporcionar una copia de los puntajes de sus exámenes estandarizados al Director de UBELL. (PARCC, PSAT , SAT/ACT)

What is your Parent's Email Address? Cuál es el correo electrónico de tu padre/madre? *

I.e.: janedoe@gmail.com

What is your Parent's Cell Phone Number? Cuál es el numero celular de tu padre/madre? *

I.e.: 2011234567 or 201-123-4567

What is your Email Address? Cuál es tu correo electrónico? (not your school email *we cannot send you information to NPS email) *

I.e.: janedoe@gmail.com

What is your Cell Phone Number? Cuál es tu numero de celular? *

I.e.: 2011234567 or 201-123-4567

What is the Student's School ID Number? Cuál es el numero de tu targeta de identidad?

Your school ID number may be located on your official Newark Public School report card or transcript.

What is your Guidance Counselor's Name? Cuál es el nombre de tu consejio/a?

What is your Guidance Counselor's Phone Number? Cuál es numero de teléfono de tu consejero/a?

Do you participate in the subsidized lunch program at your school? Participas en el programa del almuerzo de la escuela? *

If yes, please indicate your eligibility:/ Si es Si, por favor indicar su elegibilidad. *

Family Income Authorization/ Autorización de Ingreso Familiar

I authorize my child's school to release my Family Income Verification or I will provide a copy to the Consortium for participation in the Consortium for Pre-College Education in Greater Newark/Upward Bound English Language Learners (UBELLs).

Parent's/Guardian's Full Name is Required in the space provided. Nombre completeo de tu padre/tutor *

I.e., Jane Doe, Parent

Section 2: Waiver of Liability/Photo Media Release/ Seccion 2: Renuncia a Todo Responsabilidad/Medios de Comunicacion (Fotográficos)

Agreement/ Contracto

In consideration of being permitted to participate in any way in the Center for Pre-College Programs-Consortium for Pre-College Education in Greater Newark/Upward Bound for English Language Learners (UBELLs) program, hereinafter called “Activity”, I, for myself, my heirs, personal representative or assigns, do hereby waive liability, release and forever discharge NJIT, its officers, agents, trustees, or employees from any and all demands, rights, and causes of action of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, including death, resulting from my voluntary participation in or in any way connected with the Activity. Participation in the Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Injuries could range from range from scratches, bruises, cuts, eye injury or loss of sight, joint or bodily injuries, catastrophic injuries including paralysis and death. I have read the previous paragraphs and I acknowledge, know, understand and appreciate these and other risks that are inherent in any Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. In addition, I hereby freely and irrevocably grant to NJIT and its authorized employees and agents, the absolute right and permission to copy, exhibit, copyright, use, take, distribute and/or publish my photographic likeness, name, voice, and/or image made in relation to my participation in the Activity in photographs, video and in any and all other media forms.

Parent's/Guardian's Full Name and Student's Full Name are Required in the space provided./ Nombre completo del padre/ tutor y nombre completo del esudiante es requerido *

Please provide parents/guardians full name first, I.e., Jane Doe, Parent; press enter key and type students full name, i.e. John Doe, Student on the second line.

Section 3: Household Information/ Sección 3: Información del Domilcillo

With whom do you live with? Con quien vive el esudiante? *

If you live with a guardian or other, please state name and relationship/ Si vives con un tutor, por favor proveer el nombre y relación. Ejemplo, Juana Ortiz, Tia

Example: Jane Doe, Aunt

Parents/Guardians Marital Status/ Estado Civil de tus padres *

What is your Mother/Guardian Level of Education? Cuál es el nivel de estudio de tu madre? *

What is your Father/Guardian Level of Education? Cuál es el nivel de estudio de tu padre? *

How many people are in your household? Numero de personas en el domicilo *

Family Yearly Income Average? Ingreso familiar anual *

Proof is Required / Prueba de ingreso es requerido

I agree that the above information is correct to the best of my knowledge. Estoy de acuerdo que la información anterior es correcta. *

Parent's/Guardian's Full Name is Required in the space provided. I.e., Jane Doe, Parent/ Nombe del padre complet es requerido en este espacio.

Section 4: Upward Bound English Language Learners (UBELL) Contract and Standardized Test Scores Request/ Sección 4: Contracto de Participación y Resultados de los Exámenes Estandarizados

Contract of Participation/ Contracto de Participación

I would like to be a participant in the Consortium Upward Bound for English Language Learners (UBELLs) program because it will provide me with the encouragement and preparation I need to pursue higher education. I realize that participation in the program will ensure that I have access to tutoring services in academic subjects, and preparation for the PARCC, PSAT, and SAT/ACT tests. I will also have the opportunity to visit colleges, businesses and other educational industries. In the summer, I will have the opportunity to participate in a summer enrollment program including staying on a college campus. I will, as well as my parent(s)/guardian(s), make a commitment to become involved in tutoring, mentoring, and college and career workshops on topics such as the admission process, financial aid, and choosing the right college. I will also commit to reviewing with my child and signing a Personal Education Plan (PEP) when requested by Consortium personnel. In addition to these activities, I will also have the opportunity to interact with other TRIO students across the state.

Parent's/Guardian's Full Name and Student's Full Name are Required in the space provided/ Nombre completo del padre o guardian es requerido. *

Please provide parents/guardians full name first, I.e., Jane Doe, Parent; press enter key and type students full name, i.e. John Doe, Student on the second line.

Standardized Test Scores/ Resultados de los Exámenes Estandarizados

As a requirement of participation in the Upward Bound English Language Learners (UBELLs) programs, we must receive a record of your final grades and standardized test scores as needed. This includes a copy of my report card/transcript (transcripts may be unofficial) for every marking period and test results when they become available. I hereby grant permission for my school to release my transcript/report card and SAT and other test scores to Upward Bound for English Language Learners (UBELLs) program of the New Jersey Higher Education for the purposes of program evaluation.

Parent's/Guardian's Full Name and Student's Full Name are Required in the space provided/ Nombre completo del padre o guardian es requerido. *

Please provide parents/guardians full name first, I.e., Jane Doe, Parent; press enter key and type students full name, i.e. John Doe, Student on the second line.

Name of the Student's Physician. Nombre del doctor del estudiante.

Example: Dr. J. Doe

Student Physician's Telephone Number. Numero de teléfono del doctor del estudiante.

I.e.: 2121234567 or 212-123-4567

Name of your health insurance company. Compañia del seguro medico.

Health Insurance Policy Number. Número de póliza.

Health History Conditions? Historial de condiciones médicas. *

If yes, what is the condition? Si es Si, cual es la condición?

Example: Allergic to Penicillin, Asthmatic, etc. Additional information may be requested. Can also be shared in person.

Emergency Contact Person. Nombre de contacto para emergencias. *

Name of Contact Person. I.e., Jane Doe

Telephone Number of your Emergency Contact Person. Numero de telefono para emergencias. *

Cellular Phone Number Recommended. I.e., 201-123-4567 or 2011234567

Relationship of the Emergency Contact Person with the student. Relación del contacto para emergencias con el estudiante. *

Example: Uncle, Mother, Father, Neighbor, etc.

Permission to Participate in All Program Activities/ Permiso de Participación in tods las actividades

I hereby give permission for her/him to participate in all activities organized by the Consortium for Pre College Education in Greater Newark/Upward Bound for English Language Leraners (UBELLs). In case of an injury, I grant permission for her/him to receive medical attention deemed necessary, by qualified medical personnel, during the entire time that he/she (listed within) is participating in the Consortium for Pre-College Education in Greater Newark. Please Note: Listing of Field Trips will be provided on a later date.

Parent's/Guardian's Full Name is Required in the space provided/ Nombre completo del padre/guardian en este espacio *

I.e., Jane Doe, Parent

Parent/Guardian- Padre/Guardian

Every reasonable precaution will be taken to provide for the safety and care of your son or daughter. Every effort will be made to notify you in the event of an accident or injury, which may require emergency care. If you cannot be contacted, permission is granted to the staff of the Consortium to seek medical attention. All financial responsibility for hospitalization and medical care provided, in the case of an emergency, is to be assumed by the parent or guardian.

Parent's/Guardian's Full Name is Required in the space provided/ Nombre completo del padre/guardian en este espacio *

I.e., Jane Doe, Parent

AGREEMENT/ CONTRACTO

I certify that my child and I (Parent/Guardian) to the best of my knowledge that the information provided is accurate and complete and that any material omissions or false statements can result in termination of my child participation in the program. I authorize the Consortium for Pre-College Education in Greater Newark/Upward Bound for Englsih Language Learners (UBELLs) to make an inquiry regarding Standardized Test Scores, Family Income Verification, and all pertinent information required by the program. Program acceptance will be confirmed by authorized Consortium/UBELLs staff and may include an e-signature version of this application.

BY SIGNING BELOW, I certify that I have read and agree with these statements/ Firma del padre/guardian *

Please provide parents/guardians full name first, I.e., Jane Doe, Parent; press enter key and type students full name, i.e. John Doe, Student on the second line.