College Bound North County Project Jumpstart Academy - Phase I and II Registration Application

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On-line Registration Application

Email *

Scholar Last Name *

Scholar First Name *

Gender *

Female

Male

Which College Bound North County Project Jumpstart Program do you want to Apply for Registration? (Please select only one) *

Phase I - For 6th - 8th Grade Scholars and their Parents/Guardians ONLY (July 26th - July 30th)

Phase II - For 9th - 12th Grade Scholars and their Parents/Guardians ONLY (Once a month from August 2021 - December 2022)

Please select which Community/Civic Based Organization referred you to the CB NC Project Jumpstart Academy? *

Concerned Parents Alliance/College Bound Programs

Delta Sigma Theta Sorority, Inc.

Alpha Kappa Alpha Sorority, Inc. North County Chapter

North County African American Women's Association

NAACP North County Chapter

UC San Diego

Cal SOAP

Urban League of San Diego County

Neighborhood House

Jack and Jill of America North County Chapter

Sigma Gamma Rho Sorority, Inc.

National Sorority of Phi Delta Kappa

Other

Scholar's Grade Level for 2021-2022 Academic Year (Each scholar must have their own registration application) *

6th grade Scholar

7th grade scholar

8th grade scholar

9th grade scholar

10th grade scholar

11th grade scholar

12th grade scholar

Name of Middle School or High School *

Name of North County School District *

Scholar Email Address *

Scholar Cell # *

Home Address (Include Street address, name, city and zip code please) *

Shirt Size *

Race / Ethnicity *

African American / Black

American Indian

Asian American / Pacific Islander

Latin - X

White / Caucasian

Other

Select all that apply

Overall Cumulative GPA (as of most recent school year) *

Will your scholar require transportation to and from the Phase I Academy? *

Yes

Has your scholar been COVID vaccinated? *

Yes

Decline to State

Parent / Guardian Last Name *

Parent / Guardian First Name *

Parent / Guardian Email Address *

Parent / Guardian Cell # *

I agree for CPA to register my cell phone with their College Bound North County Project Jumpstart Academy Group Me for on-going communications. *

Yes

Please list the name of your scholar's medical insurance, their member Card Number, Name of Doctor and Contact Information. *

I acknowledge that if my scholar has any behavioral challenges or engages in any illegal activities during this academy, I will be responsible for immediately picking up my scholar and paying for any related damages or expenses. *

Yes

I agree to my scholar wearing their masks at all times, having their temperature checked and social distancing while attending the CB North County Project Jumpstart Academy. *

Yes

I agree to my scholar being photographed, videotaped and/or interviewed as it relates to the marketing of the CB North County Project Jumpstart program, pre and post evaluations and/or program assessments. *

Yes

I hereby waive all claims that I may have against the Concerned Parents Alliance, Poway Unified School District, their officers, agents, and employees for injury, accident, illness, or death occurring during or by reason of the College Bound North County Project Jumpstart Academy. *

Yes

Medical Authorization: In the event of an accident or sudden illness, the Concerned Parents Alliance, Inc., Poway Unified School District staff, have my permission to facilitate whatever emergency medical treatment might be deemed necessary for my scholar. *

Yes

As the Parent/Guardian of the above scholar, I/We waive the right to any claim against Concerned Parents Alliance (CPA), Poway Unified School District (PUSD) or any of its partners, affiliates, etc. related to or arising from the acquisition of or exposure to any infectious disease. Neither CPA, PUSD, nor any of its partners or affiliates, nor any of its employees or agents shall be liable for any claims of loss, expense, or damage to participant relating to the acquisition of or exposure to any infectious disease. CPA AND PUSD MAKE NO WARRANTY WITH RESPECT TO THE SAFETY OF THE PREMISES OR ACTIVITIES WITH REGARD TO ANY INFECTIOUS DISEASE. *

Yes

Please list any additional information we may need to know about your scholar to ensure they will be successful in the College Bound North County Project Jumpstart Academy (Phase I or Phase II)

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