Pensacola State College-TS

TRIO-Educational Talent Search
Middle School Needs Assessment Survey

Questionnaire
You have indicated an interest in participating in the TRIO-Educational Talent Search Program. To help us better determine what your needs are, we would like to ask you to fill out this questionnaire.
Name*

FirstMiddleLast
Date

MonthDayYear
mm-dd-yyyy
School Attending
Grade
Please select each area for which you would like to receive assistance/information:

Study SkillsTest-Taking StrategiesCareer PlanningDecision-MakingGoal-SettingCollege InformationTutoringOther
I would like to be in the TRIO-Educational Talent Search program because
Who referred you?
Student Signature*

Clear
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities, or employment. For inquiries regarding Title IX and the College’s nondiscrimination policies, contact the Executive Director, Institutional Equity and Student Conduct at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.

Program Overview
Dear Parent or Guardian:

Your child has expressed an interest in the Pensacola State College TRIO Educational Talent Search (ETS) Program. This educationally focused program is designed for young people who have a Grade Point Average of 2.0 or higher, who have academic potential to complete their middle and high school education, and who desire to continue their education or training beyond high school. The TRIO ETS Program will help your child to achieve his/her educational goals and to pursue a college education or vocational training after high school.

The TRIO ETS Program provides students a number of free services including FREE TUTORING. Students may receive individual, educational and vocational advising, financial aid/scholarship application assistance, and college preparation/admission assistance. Students are encouraged to participate in ETS sponsored field trips to various college campuses; explore personal interests and career goals; attend workshops aimed at ACT/SAT preparation; development of study skills, test-taking strategies, career planning, decision making, goal setting skills and more.

Student participation in the ETS program requires both student and parent involvement, as listed below. All financial information is CONFIDENTIAL and, unless specifically authorized by you, only TRIO ETS professional staff will have access to this information.

Parental involvement:
• Parental Consent form completed and signed
• Family Information form completed and signed
• Verification of family income: a) last year’s income tax 1040 form, b) proof of untaxed income (AFDC,
Social Security)
• Participate in ETS sponsored family workshops as needed

Student involvement:
• Maintain high academic standards, (minimum 2.0 Grade Point Average required)
• Meet regularly with assigned student services (ETS) counselor
• Participate in weekly planned activities, field trips, seek tutoring assistance as needed, complete and return
assignments to ETS counselor
• Attend informative workshops
• MUST complete and submit college applications (12th grade)
• MUST provide copies of college acceptance letters to assigned ETS counselor (12th grade)
• MUST meet with an ETS counselor to submit a Free Application for Federal Student Aid (FAFSA) or provide ETS counselor with proof of submission of the FAFSA (12th grade)
• Will enroll in a 2 or 4 year college/university OR a vocational or specialized training program after high school graduation

Upon review of the application packet, it will be determined if your child meets the eligibility requirements of the program and would benefit from the services offered. If you have any questions regarding your child’s participation in the TRIO ETS Program, please contact us at the Pensacola State
College - Pensacola Campus office (850-484-1620).

Juanita Edwards
Program Director
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities, or employment. For inquiries regarding Title IX and the College’s nondiscrimination policies, contact the Executive Director, Institutional Equity and Student Conduct at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.

Notification of Social Security Number Collection and Usage
In compliance with FL Statute 119.071(5), Pensacola State College (PSC) issues thisnotification regarding the purpose of the collection and use of a Social Security Number (SSN) in relation to the student’s participation in the Educational Talent Search (ETS) Program.

PSC collects Social Security Numbers for use in performance of the College’s and ETS Program duties and responsibilities. To protect the student’s identity, PSC will secure the Social Security Number from unauthorized access. PSC will never release a Social Security Number to unauthorized parties. As an ETS participant, the SSN is used for all associated educational purposes and federal USDOE reporting requirements.

The public school system in Florida uses the Social Security Number as a student identifier (section 1008.386, F.S.). In a seamless K-12 system, it is beneficial for postsecondary institutions to have access to the same information for purposes of tracking and assisting students in the smooth transition from one education level to the next. All Social Security Numbers are protected by federal regulations and are never released to unauthorized parties.

Financial Aid
A student’s Social Security Number is required for the following financial aid purposes: The United States Department of Education’s (USDOE) Free Application for Federal Student Aid (FAFSA) requires all applicants to report their SSN to be used for all federal financial aid programs as a student identifier for processing and reporting. In addition to its use by USDOE as a student identifier, the SSN is required in order for the Department of Homeland Security to investigate citizenship status, for the Federal Work Study Program, and is required on all loan applications for use by the lender/servicer/guarantor. PSC collects a student’s SSN on certain institutional scholarship applications for student files and federal and state audit/reporting purposes. If you are a recipient of a State of Florida grant or scholarship such as the Florida Student Assistance Grant, Florida Work Experience or Bright Futures the State of Florida Department of Education will require the use of the SSN on their grant/scholarship disbursement website and for reporting purposes.
Student Name

First NameLast Name
Student SSN*
999-99-9999
Parent's Signature*

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
Consent to Communication by Text Message

By signing this form, I authorize the TRIO Educational Talent Search (ETS) Program at Pensacola State College (PSC) to send text messages to my cell phone to convey information regarding upcoming events, services provided, and important information related to student academics. I understand that standard text messaging rates will apply to any messages received from TRIO ETS. I agree not to hold TRIO ETS or PSC liable for any electronic messaging charges or fees generated by this service. I further agree that in the event my cell phone number changes I will inform the TRIO ETS Program.
Parent's Signature*

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities, or employment. For inquiries regarding Title IX and the College’s nondiscrimination policies, contact the Executive Director, Institutional Equity and Student Conduct at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.

Photography Release Form
This Photography Release Form confirms the agreement between you and The District Board of Trustees of Pensacola State College, Florida (the “College”) regarding your participation in the College’s Educational Talent Search Program in which you may be photographed or videotaped (the “Property”).

For valuable consideration received, you hereby irrevocably grant to the College perpetually, exclusively, and for all media throughout the world (including print, non-theatrical, home video, CD-ROM, internet and any other electronic medium presently in existence or invented in the future), the right to use and incorporate (alone or together with other materials), in whole or in part, for advertising, publicity, or any other purpose, photographs or video footage taken of you as a result of your participation in the College’s Educational Talent Search Program.

You hereby agree that you will not bring or consent to others bringing any claim or action against the College on the grounds that anything contained in the Property, or in the advertising and publicity used in connection herewith, is defamatory, reflects adversely on you, violates any other right whatsoever, including, without limitation, rights of privacy and publicity. You hereby release the College, its trustees, officers, employees, agents, successors and assigns from and against any and all claims, demands, actions, causes of action, suits, costs, expenses, liabilities, and damages whatsoever that you may hereafter have against the College in connection with the Property.

This agreement shall not obligate the College to use the Property or to use any of the rights granted hereunder, or to prepare, produce, exhibit, distribute or exploit the Property.

The College shall have the right to assign its rights hereunder, without your consent, in whole or in part, to any person, firm or corporation.
Date you AGREE AND ACCEPT above terms

MonthDayYear
mm-dd-yyyy
Note: It is not required that this Photography Release Form be officially notarized. Witnesses will not be discriminated against due to age, gender, or relationship to participant/parent or guardian of participant. All Witnesses must sign and print their names in the appropriate areas to verify and affirm the validity of the Photography Release Form.
Student Signature*

Clear
Student Name

First NameLast Name
Parent Signature*

Clear
Parent Name

First NameLast Name
Witness 1 Signature

Clear
Witness 1 Name

First NameLast Name
Witness 2 Signature

Clear
Witness 2 Name

First NameLast Name
School Student Attends
Grade
Other organizations/clubs student is involved in (Lamplighters, Take Stock in Children, etc.):
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities, or employment. For inquiries regarding Title IX and the College’s nondiscrimination policies, contact the Executive Director, Institutional Equity and Student Conduct at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.

Records Release
Please have a friend, family member, or coworker witness this form.

RECORDS RELEASE

ESCAMBIA COUNTY, FLORIDA SCHOOL DISTRICT
I,__________________________________, hereby certify that I am the parent or guardian...

Parent First NameParent Last Name
...of

Student First NameStudent Last Name
DOB of Student

MonthDayYear
mm-dd-yyyy
I hereby authorize the release of information and/or records concerning said student in the custody and/or control of the Escambia County School District or its employees to:

Pensacola State College TRIO Educational Talent Search Program
1000 College Blvd. Pensacola,FL 32504

I hereby waive any privacy claims under FERPA, HIPPA, or other applicable law for such release of records. The release is valid and shall continue in force until revoked by me in writing, furnished to the office of the School Board General Counsel, 75 North Pace Boulevard, Pensacola, FL 32505.
Signature*

Clear
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date

MonthDayYear
mm-dd-yyyy
WITNESSED BY:

(Note: cannot be witnessed by the person receiving the records, must be a third party)
Witness Signature

Clear
Witness Name

First NameLast Name
Witness Address

Street Address

Street Address Line 2

CityState

Zip Code
Date

MonthDayYear
mm-dd-yyyy
School Student Attends
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities, or employment. For inquiries regarding Title IX and the College’s nondiscrimination policies, contact the Executive Director, Institutional Equity and Student Conduct at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.