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Liberty Partnerships Program (LPP)

Syracuse University 200 Huntington Hall Syracuse, NY 13244 315-443-5181 FAX 315-443-9878 Email: dbmeyer@syr.edu

Dear Parent/Guardian: Your child has been recommended for, or has expressed an interest in, the Syracuse University Liberty Partnerships Program. Funded by New York State, LPP offers a broad range of services to improve students ability to complete high school and successfully prepare to enter college or the workforce upon graduation. Our program serves students in grades 6 -12. The program is scheduled as part of the students school day with some extracurricular opportunities offered after school and/or on weekends. We encourage students to continue with LPP through the completion of high school. If they do so, they will be eligible for a half tuition scholarship to Syracuse University and several other LPP institutions around New York State, as well as to specific Syracuse University scholarship opportunities, such as Say Yes to Education and Syracuse Challenge. Please read, complete, and sign the application where indicated. Together we can build a bright future for your son/daughter. I can be contacted at 443-5181 or you may contact the designated LPP coordinator at your childs school. Sincerely, Deborah Meyer
Project Director



Student ENTRY APPLICATION SCSD ID#_____________________

SYRACUSE UNIVERSITY LIBERTY PARTNERSHIPS PROGRAM (LPP) This New York State funded program is designed to provide services to help improve students academic performance and potential for success. This form must be completed by each students parent or guardian for the enrollment process to be completed.
Student Name: _____________________________________________ Address: __________________________________________________ __________________________________________________ Ethnicity: (please check one) Parent Date of Birth: ______________________ Gender:______ Grade:______ School:_____________________________ email___________________________________________

Student email__________________________________________ 1. 2. 3 4. 5. 6. 7. 8. African American White, non-Hispanic Hispanic/ Latino(a) American Indian/Alaskan Native Asian Hawaiian or Pacific Islander Bi-racial or Multi-racial Other _____ _____ _____ _____ _____ _____ _____ _____

Who referred you to LPP?_______________________________________________________________________________ Name Position Grade at first entry into LPP: __________ Date of first entry into LPP:___________ Parent(s)/Guardian(s) Name: ______________________________________________________________________________________________ Home Phone: ___________________ Cell Phone: ___________________ Work Phone: ______________________

Address (if different): _____________________________________________ Email: ____________________________________ ____________________________________________ In case of emergency contact: Name: _____________________________________________________________ Phone: ___________________________

Address: _______________________________________________ Relationship to Student: _____________________________ _____________________________________________ IS STUDENT CURRENTLY RECEIVING TUTORIAL ASSISTANCE FROM ANOTHER PROGRAM? CHECK ALL THAT APPLY. _____ S.U. STEP_____ Gear Up _____Upward Bound _____Hillside _____ OCC LPP ______Other (specify)

LPP Program/Student/Parent Agreement Contract

To achieve the goals of the Program, a joint commitment is required between the LPP program, the student, and the students family involving the following elements:

The Syracuse University Liberty Partnerships Program will: Provide students with services to improve their ability to complete high school and to advance to postsecondary education and the workforce. Dollars for Scholars The LPP Program awards scholarship aid to graduating seniors in order to help them continue their education. LPP students have to meet specific requirements in order to qualify for this aid. LPP Scholarships Several colleges and universities, who host LPP, offer half-tuition scholarships to qualifying LPP students. Students must apply and be accepted to these universities in order to receive scholarship funds.

I agree to participate fully in the LPP program. I understand that I must be an active participant in the program, regularly attend LPP bring homework or other work to study use my time productively be cooperative and respectful to all, staff and students Students signature: ________________________________________________ Date:___________________________ .

PARENT AGREEMENT I agree to support my childs participation in the Syracuse University Liberty Partnerships Program.
Parent/Guardian Signature: _____________________________________________ Date: ___________________________


I grant permission for my son /daughter_______________________________________ (Student Name) to participate in the Syracuse University Liberty Partnerships Program at ___________________________________________________________________________ (Name of School) I authorize Liberty Partnerships Program personnel to obtain and review my childs school records, and I understand that records will be used in planning appropriate academic support and counseling _ervices (academic, career and personal) for my son / daughter. I understand that all of the s information will be kept confidential to the extent required by law. Parents/Guardians signature: ________________________________________________________date:__________

Media Release
I grant permission for my childs photograph (whether still, motion, or television) writings, and/or recordings of his/her voice taken during the course of the program to be used in LPP publications and promotions. Parents/Guardians Signature: ________________________________________________________date:____________ _ _

Rev. 9/12dm