Le Moyne College
Higher Education Preparation Program
Upward Bound Program
Current Student Application Update
SUMMER 2016
STUDENT NAME: ______
LastFirstM. I.
ADDRESS: ______
Number and Street Apt. #
______
CityStateZip Code
PHONE NUMBER: (______)______EMAIL:______Date of Birth:______
Month/Day/Year
GENDER: Male ______Female ______
NAME OF PRESENT SCHOOL: ______
SCHOOL ID#: ______GRADE: ______
NAME OF GUIDANCE COUNSELOR: ______
THE FOLLOWING SECTION IS TO BE COMPLETED BY PARENT/GUARDIAN/, ETC.
NAME OF FATHER OR GUARDIAN: ______
ADDRESS (if different): ______
______email ______
BUSINESS PHONE: (______)______HOME PHONE: (______)______
OCCUPATION: ______EMPLOYER: ______
NAME OF MOTHER OR GUARDIAN: ______
ADDRESS (if different): ______
______email ______
BUSINESS PHONE: (______)______HOME PHONE: (______)______
OCCUPATION: ______EMPLOYER: ______
PLEASE NOTE THE BESTIME TO CONTACT YOU FOR A HOME VISIT: ______
______
WE (STUDENT AND PARENT/GUARDIAN) CERTIFY THAT ALL THE INFORMATION PROVIDED ON THIS APPLICATION IS CORRECT.
______
Signature of Parent/GuardianDate
______
Signature of StudentDate
Please return by Monday, March 7, 2016
Le Moyne College
HEPP/Upward Bound Program
EMERGENCY MEDICAL TREATMENT AUTHORIZATION
Student: ______Date of Birth: ______Age:______
Gender: ____M____F Height:______Weight: ______
Address: ______
City/State/Zip Code: ______
Parent/Guardian Home Phone:______Cell:______
Le Moyne College
HEPP/Upward Bound Program
HEALTH INFORMATION
Below please check any current health condition that may require attention during the Program day. Also complete and submit the Medication Authorization Form if your child has health conditions that require medication during the Program day.
Allergies / Sensitivities (be specific)
Foods______
Medicines______
Bee sting or insects
Bite______
Other______
Asthma Inhaler required at Program Vision Problems Glasses Contacts
Hearing Problems Hearing Aid(s) ADD/ADHD Other______
List all medications and dosages your child receives on a continual basis: ______
______
Please return with the Current Student Application Due Monday, March 7, 2016
LE MOYNE COLLEGE
HIGHER EDUCATION PREPARATION PROGRAM
UPWARD BOUND PROGRAM
SUMMER 2016
GUIDANCE COUNSELOR RECOMMENDATION FORM
THIS FORM IS TO BE COMPLETED BY SCHOOL GUIDANCE COUNSELOR: Please complete this form immediately and return it with a copy of student's school transcript, available state assessments (NYS Math and ELA Assessments), and AP courses.
STUDENT NAME: ______
SCHOOL: ______GRADE: ______GPA: ______
Please respond as indicated: Yes, No or N/A - student did not take state assessment or scores not available
Did student achieve at the proficient level on state assessments in:
reading/language arts(Y/N/NA)______math (Y/N/NA) ______
Limited English Proficiency Yes______No______Unknown______
(if applicable)
SCHOOL ADDRESS: ______SCHOOL ID#: ______
YOUR NAME:______
SCHOOL PRINCIPAL: ______
YOUR SIGNATURE: ______DATE: ______
Return no later than Monday, May 2, 2016 to:Le Moyne College
Upward Bound Program
Fax: 315-445-45341419 Salt Springs Rd
Email: Syracuse, NY 13214
LE MOYNE COLLEGE
HIGHER EDUCATION PREPARATION PROGRAM
Upward Bound Program
Summer 2016
PHYSICIAN FORM
THE FOLLOWING PAGES ARE TO BE COMPLETED AND SIGNED BY A PHYSICIAN, HEALTH CENTER, OR CLINIC.
STUDENT NAME: ______
DATE:______
TO THE PHYSICIAN:
Please review, complete and date all required immunizations. If records are unobtainable, re-immunization is necessary for registration.
A. TETANUS-DIPHTHERIA
1.Completed primary series of tetanus-diphtheria immunization
____/____/____
mo day year
2.Received tetanus-diphtheria booster within the last 10 years
____/____/____
mo day year
B. TUBERCULOSIS - MUST BE AFTER September 1, 2015 (Check appropriate space)
Updated PPD test needs to be complete or
PPD test results card attached.
1. ____ PPD (Mantoux) test within the past year (Tine or monovact not acceptable).
Give date and text results ...... ……………………………… ____/____/____
mo day year
Result: _____ positive
_____ negative
2. ____ Positive PPD-Chest (x-ray required).
Give date and result of chest x-ray ...... ____/____/____
mo day year
Result: _____ positive
_____ negative
3. ____Had BCG vaccine-Chest x-ray required if PPD not done
Give date and result ...... ____/____/____
mo day year
Result: _____ positive
_____ negative
( over )
THE FOLLOWING CRITERIA APPLIES TO INDIVIDUALS BORN AFTER 1956.
C. MEASLES-TWO DOSES with LIVE VACCINE after 1967
1. First dose (on or after 1st birthday) ...... ____/____/____
mo day year
2. Second dose (at least 30 days after 1st dose) ...... ____/____/____
mo day year
(or) Physician verified clinical illness ...... Year 19______
(or) Protective Antibody Titer ...... Result ______Date ______
D. RUBELLA
One dose with Live Vaccine on or after 1st birthday …………………………………...... ____/____/____
____ Protective Antibody Titer ...... Result______Date ______
NOTE: PREVIOUS CLINICAL DIAGNOSIS OF RUBELLA IS NOT SUFFICIENT.
E. MUMPS
One dose with Live Vaccine on or after 1st birthday ……………………………………………..... ____/____/____
mo day year
(or) Physician verified clinical illness ...... ____/____/____
mo day year
(or) Protective Antibody Titer ...... Result ______Date ______
F. POLIO
1. Completed primary series of polio immunization ...... ____yes ____no
Type of vaccine ...... ____ Oral ____ Inactivated ____ E-IPV
Last booster ...... ____/____/____
mo day year
Name of Physician (please print):______
Address: ______
Phone Number: ( ) ______
Physician's Signature: ______
Please return Physician Form, no later than Monday, May 2, 2016 to:
HIGHER EDUCATION PREPARATION OFFICE/UPWARD BOUND PROGRAM
LE MOYNE COLLEGE - ROMERO HALL
1419 SALT SPRINGS RD.
SYRACUSE, NEW YORK 13214-1301