Program Application Form

Note to Students & Parents/Guardians:

STUDENTS: COMPLETE ITEMS 1-18.

PARENTS/GUARDIANS: COMPLETE REMAINDER OF APPLICATION.

Students will be notified by mail if they are eligible for admission and/or acceptance for participation in the TRIO Talent Search program after we receive and process this application. Please make sure the application is complete in order to prevent processing delays.

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* 1. Student's Name

First:

Middle:

Last:

Name preferred:

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* 2. Mailing Address:

Street:

City:

State:

Zip Code:

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* 3. Student's Birth Date:

Month

Day

Year

Current Age

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* 4. Gender:

Female

Male

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* 5. Ethnicity:

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* 6. Are you a U.S. citizen or Permanent Resident?

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* 7. Phone Number:

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* 8. Alternate Contact Phone Number:

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* 9. Email Address:

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* 10. Which school do you currently attend?

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* 11. What grade are you in?

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* 12. Year you expect to graduate high school:

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* 13. On your child's most recent report card, did they have a grade below a "C" in a core academic subject (English, math, science, social studies)?

Yes

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* 14. During the previous 9 weeks, has your child been suspended or had other disciplinary issues at school?

Yes

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* 15. How did you hear about Talent Search? Check all that apply:

School Teacher/Counselor

Advertisement at School

Parent/Guardian, Family Member, or Friend

Registration Table

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* 16. Why are you interested in joining Talent Search?

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* 17. What are your plans after high school graduation?

2-year college

4-year college

Technical College

Military

Work

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* 18. Do you have any special needs we should be aware of? If so, please explain.

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* 19. Please indicate the Talent Search services you need and/or would like to receive. Check all that apply:

Academic tutoring

Study/Test-taking Skills

Goal setting

Self esteem

Career guidance

ACT Prep

Financial Literacy

College information & preparation (campus tours, admissions applications, scholarships, financial aid/FAFSA assistance)

Cultural/educational field trips

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* 20. If accepted into Talent Search, I, the student agree to: maintain at least a 2.0 GPA; attend and participate in scheduled meetings, workshops, tutoring, or other program sessions/offerings that may be relevant to me; have a desire to go to college; refrain from having discipline/behavior problems at school; show respect to myself and others; successfully be promoted to the next grade; attend school regularly; seek help from teachers/school staff and/or my Talent Search counselor when needed; make every effort to enroll in college after high school graduation.

By typing my full name below, I certify that I, the student, understand what is expected of me as a Talent Search participant as indicated above.

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* 21. Date of application:

Current Date

Date

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* 22. Parent/Guardian's Name (First and Last)

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* 23. Relationship to Student:

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* 24. Your preferred language:

English

Spanish

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* 25. Does your student live in a single-parent family?

Yes

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* 26. How many family members live in your home?

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* 27. Please indicate your taxable family income (after deductions) for last year. This information can be found on your tax return form 1040 line 43. (1040EZ line 6, 1040A line 27) This is NOT your gross income.

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* 28. Does either of the student's biological parents have a high school diploma?

Yes

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* 29. Did either of the student's biological/adoptive parents (single parent households only answer for the parent the student lives with) earn a 4-year college degree or higher?

Yes

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* 30. Does your student qualify for and/or receive Free/Reduced lunch at school?

Yes

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* 31. PARENT'S AUTHORIZATION FOR RELEASE OF SCHOOL RECORDS:
I, the student's parent/guardian, am aware of my student's interest in Talent Search. I hereby authorize the staff of the program to request information from and share information with my student's school, teachers, and counselors. I grant permission for necessary school records to be released to program staff, including class schedules, report cards, transcripts, free/reduced lunch eligibility, contact information, disciplinary records, ADA information, FAFSA confirmation, iNow reports, etc.

PARENT'S AUTHORIZATION FOR RELEASE OF POSTSECONDARY EDUCATION RECORDS
I, the parent, hereby authorize any college(s) my student may attend to release to Talent Search staff, upon request, my student's college academic and enrollment information and student aid reports until my student completes a certificate or degree from said college.

PARENT'S AUTHORIZATION FOR STUDENT PARTICIPATION & PROMOTIONAL RELEASE
I, the parent, hereby give permission for my student to participate in Talent Search activities, which may include workshops on sensitive issues. I also consent to the use of my child's name, photograph and/or video recordings for editorial, educational, and/or promotional use by the Talent Search program.

CONFIDENTIALITY AGREEMENT
I understand that Talent Search is a federal program authorized by the U.S. Department of Education. I also understand that the information I have provided will be used to document my student's eligibility for participation in the Talent Search program and that all information will be held confidential by Talent Search program staff.

By typing my full name below, I certify that I, the parent, have read and consent to all of the above statements.