LPP Application Form

* = required field

Some content may be updated based on selection

Liberty Partnerships Program: Application for Enrollment. Please fill out ALL fields. Your application will not be considered otherwise.

First Name

Middle Initial

Last Name

Grade Level

Name of School

Home Address

City:

State:

Zip:

Home Phone

Cell Phone

Ethnicity

Gender

Check if you are currently enrolled in Syracuse UniversiAre you ccurrently enrolled in Syracuse University's LPP or LeMoyne's LPP

YES

Parent/Guardian First Name:

Last Name:

Parent/Guardian Email Address:

Parent/Guardian Home Phone

Parent/Guardian Cell Phone

Emergency Contact First Name:

Last Name:

Emergency Contact's relationship to student

Emergency Contact Phone Number

As the parent/guardian of the student, I consent and grant permission for my student to participate in the SUNY Onondaga Community College Liberty Partnerships Program (LPP) at the selected high school noted on the form. In addition, I grant the high school/SCSD the ability to release and share all necessary student records and documentation with SUNY OCC's LPP for my student which may include: all progress reports, report cards, IEPs, testing reports, discipline records, attendance records, school ID numbers and/or ID cards, social security numbers, medical records and any other documentation needed to effectively support the academic, social, emotional, college readiness and career development. I understand that these records will be kept in a secure area and will be seen only by designated SUNY OCC LPP staff and documented program partners in accordance with the guidelines established by the New York State Education Department. As a result of my student participating in SUNY OCC's LPP, I understand my student is not eligible to participate in the Syracuse University LPP or LeMoyne LPP while enrolled as a high school student.

Signature of Parent/Guardian

Date

MEDIA RELEASE PERMISSION (check one) - Permission given for my child's picture to be used for the purposes of media releases (newspapers, web pages, flyers, brochures, television, etc.)

Yes

Signature of Parent/Guardian

Date

Signature of Student

Date

By filling out the signature fields above you agree that this form is filled out to the best of your knowledge and with the knowledge and consent of all parties involved.

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