Stockton University GOALS GEAR UP: Saturday Academy 2022-2023 Application- Application Note: Applications Closed
Dear Scholar,

The GOALS Team would like to thank you for soliciting your interest in the Stockton University GOALS GEAR UP program! Please complete the form in its entirety and email your most recent report card to goals@stockton.edu.

Please RSVP for our Kick-Off event Saturday October 22nd, 2022 and follow all of our social media accounts @stocktongoals for more information.
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Email *
Student First and Last Name: *
Are you a new or returning student?
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Date of Birth *
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Grade: *
School Attending *
Student Address: *
Student Personal Gmail or Email (not school email): *
Student Phone Number: *
T Shirt Size (Note all shirts are men's or unisex sizes) *
Are you a U.S. Citizen? *
Are you of Hispanic Origin? *
Race (check all that apply): *
Required
Did you email your reportcard to goals@stockton.edu? *
What elective are you interested in potentially taking during Saturday Academy? *
Are you involved in extra-curricular activities? *
What days do you have extra-curricular activities? *
Required
Parent / Guardian Name: *
Parent/Guardian E-Mail *
Mother's Name: *
Mother's Employer: *
Mother's Work /  Cell Number: *
Father's Name: *
Father's Employer: *
Father's Work / Cell Number: *
Mother's Highest level of Education *
Father's Highest level of Education *
Who does the student lives with *
Total Taxable Income: *
Family Size: *
Does / Did any relatives participate in GOALS GEAR UP? *
If you answered yes to the question above, please provide their name. *
I consent to my son/daughter’s GOALS GEAR UP application and authorize release of all necessary information, including grades and test scores. I attest the statements contained in this document are accurate and true to the best of my knowledge. Initial and date below: * *
I hereby give permission for myself/my child to be photographed, filmed and/or interviewed by television, newspaper, and/or other designated media arranged by Stockton University and sponsorship affiliates for the purpose of promoting the GEAR UP Program. I agree to the use of my/my child’s image, likeness, photograph (s), videotape and/or film recording of my/my child’s voice, conversation and sounds during and in connection with the GEAR UP Program and/or sponsored events. The GEAR UP Program has permission to use my/my child’s image in perpetuity and in all media now and hereafter devised.I understand that these uses are for the sole promotion and support of the GEAR UP Program, a nonprofit organization striving to improve students’ academic achievement as a means of successfully gaining admission into colleges and universities. I further give permission for the use of my image as the participating parent. I further acknowledge that I have read this release and I will indemnify the GEAR UP Program against any and all claims, liability and expense with respect to the above agreement. I agree to adhere to the agreement’s provisions. Initial and date below: * *
Explain why you want to participate in the GOALS GEAR UP 22-23 Saturday Academy Program? *
How have you been involved with the GOALS GEAR UP program last year academic year? (Example: trips, Saturday Program, after school program, SAT class, and workshops). If new, please type NA.   *
I consent to my son/daughter’s GOALS GEAR UP participation and authorize release of any and all records including standardized test scores and attendance records to Stockton University. Initial and date below: * *
I give my consent for my child to participate in the Stockton University GOALS GEAR UP Program. I am aware that in registering my child for participation in the Gear Up Summer Program I am waiving and releasing all claims for injuries my child might sustain out of participation in program activities as well as transportation to and from program activities. Every effort is being made to provide for safety and conduct of the student during classes, field trips and transport. Staff should not be expected however to go beyond reasonable limits to check on student behavior. Students are expected to conduct themselves in such a way as not to require the undue attention of staff. The discipline codes of Stockton University are in effect and will be strictly enforced. By signing the permission slip, you will hold harmless the Stockton University GOALS GEAR UP Program for any accidents, injuries, losses or damages, which may occur during program activities as well as transportation to and from classes, activities and field trips. I consent to my son/daughter’s GOALS GEAR UP Program application and agree to the above authorization, release and participation. Initial and date below: * *
In the event of an emergency, whom should we contact? *Please include below* the contact's name, address, phone number, their relationship to the student: * Please someone other than the caregiver/guardian/ parent provided above. *
Emergency contact #2 *Please include below* the contact's name, address, phone number, their relationship to the student: * *
I pledge that upon my acceptance into the Stockton University GOALS GEAR UP program I will abide by all rules and regulations. I will attend programming and complete all classroom and homework assignments as part of my contract, and will not have more than three lateness and/or absences. In the event that I may miss more than three days, I understand that I will be dismissed from the program. Stockton University is an institution of higher learning and I must conduct myself accordingly. If I should violate any of the rules and regulations, I am aware that I may be terminated from the program. Parents and students must read and sign the contract to make it valid. Upon signing this acceptance contract, I verify that I have read and understood the above conditions and agree to the same. Parent and student, initial and date below: * *
In the event that any problems arises while the student is participating in GOALS GEAR UP activities, parents will be notified and the student will be returned home or to the designated other responsible adult listed below by a GEAR UP Counselor. If a medical emergency arises, a GEAR UP Counselor will take the student to the nearest hospital emergency room and the parent or guardian will be notified as soon as possible. GEAR UP will need two telephone numbers for all students (day & evening) and a telephone number of another responsible adult in case the parent cannot be reached. Please type the following down below: *Students Name ,Social Security #, Date of Birth, Health Insurance Name and ID number, Home Address (City State Zip Code). Telephone where your parent/guardian can be reached in day time and evening. If your parent/guardian cannot be reached, name a designated other responsible adult who we can contact*: * *
Emergency Contact  Name and Phone Number *
Computer Lab Contract
Both student and parent please initial and date here to accept the terms and conditions above: *
Both student and parent please initial and date here to accept the terms and conditions below: *
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The following are standing medical orders. Check all of the boxes that apply: *
Required
Please initial and date below to approve the above statements: *
Does the scholar have any health or medical conditions that we should be made aware of? (This includes but is not limited to allergies (food, pollen, medication), or asthma) *
Bus Pick-up: Which school would you like to be picked up? *
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