Western Kentucky University

Office of Institutional Diversity and Inclusion

Project A.I.M.S.

Activating Interest In Minority Students

Governor’s Minority Student College Preparation Program

Academic Year 2013-2014

 

 

Student Data 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Family Data 

Your decision to omit this information will not impact your child?s acceptance in the program. All information will be used for institutional purposes only.
 
 
 
 
 
 
 
 
 
 
 
 

Student Participation Agreement 

This agreement is made and entered on this day by and between the parent(s) or guardian(s) and the Governor?s Minority Student College Preparation Program for the purpose of supporting the program and its goal to improve African American youth preparation for postsecondary education. Therefore, in consideration of all the mutual covenant herein set forth, and having a complete understanding of the student, parent and program requirements:
1. I agree to participate in the required class activities of the GMSCPP.
2. I agree to behave responsibly and respect the rights of others.
 
3. I agree to arrange transportation for my child?s participation in the GMSCPP (does not apply to certain institutions).
4. I agree to ensure that my child attends all meetings and/or workshops sponsored by the GMSCPP.
5. I agree to provide school reports and report card grades for the purpose of GMSCPP; CPE may also use the school reports for statistical purposes.
6. I agree to participate and work cooperatively with the GMSCPP staff to enhance my child?s educational development.
 
7. The program director agrees to provide carefully planned educational, interesting, and informative programs for each official meeting. S/he agrees to be available to students and parents.

Photo and Press Release Form 

I, being the parent or guardian of the student herein, hereby consent that the photographs and/or motion picture film for which (s)he posed, and/or audio recordings made of his/her voice may be used by GMSCPP, its assigns or successors, in whatever way they desire, including television; furthermore, I hereby consent that such photographs, films, and recordings, and the plates and/or tapes from which they are made shall be GMSCPP property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, plates and tapes as they may desire free and clear of any claim whatsoever on my part.
I consent.
I do not consent.
 

Student Directory 

I, the student, hereby consent to be included in the student directory of the Governor?s Minority Student College Preparation Program, for the purposes confined to GMSCPP interests only.
I consent.
I do not consent.
 

Parent(s) or Guardian(s) Acknowledgment of Student Application 

I am aware that my child is applying to the Governor?s Minority Student College Preparation Program (GMSCPP) as a student participant. I understand that my child will be in attendance from September 2013 - June 2014. I am aware that my child will be given specific instructions as to the rules and regulations of both the GMSCPP and of Western Kentucky University and that I will be required to sign permission forms.

Parent(s) or Guardian(s) Information 

 
 
 
 
 
 

I hereby give permission for my child to attend the GMSCPP. I understand that the GMSCPP will be held at Western Kentucky University and that transportation to and from the program and any other related activities will be my responsibility unless otherwise noted.
 
NOTE: A parent or guardian must electronically sign this agreement of the application cannot be considered.
 
 

Emergency Medical Treatment Form 

If a medical emergency occurs, we, the staff of the Governor?s Minority Student College Preparation Program (GMSCPP), will make every effort to contact the parent or guardian of the student to approve emergency care. In the event that we are unable to locate you, we request that you sign this permission slip for emergency care. This is to certify to all medical personnel that I am the legal parent or guardian of the student herein, and that I hereby give my permission and consent to provide emergency services to or for the above named child and that I assume full financial responsibility for the above said emergency medical service.
 

Waiver and Release Form 

I, the parent or guardian of the student herein, shall not hold GMSCPP, its members or employees, accountable or liable for any accident or injury sustained by the above named child while participating in any activity sponsored by GMSCPP while at the school, or being transported to and from any school sponsored activity. This waiver shall be in effect until changed in writing by the parent or guardian of the above named child and received by the sponsoring institution.
 

Academic Information 

I give the school permission to release academic information requested concerning my son/daughter. Furthermore, I agree to allow the school system to monitor/report on my child?s academic progress on an on-going basis as long as he/she is a participant in the GMSCPP.
 
 

 Last Modified 8/8/13