University Of Arkansas-Little Rock-TS

UA-Little Rock TRIO Talent Search Higher Education Access Program

Student Application
- Name
  
  First NameMiddle NameLast Name
- School
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Grade
- School ID #
- Email
  example@mail.com
- Address:
  
  Street/P.O. Box
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Student Cell Phone
  (999)999-9999
- Parent Phone
  (999)999-9999
- Gender:
- U.S. Citizen or Permanent Resident:
- Lunch Program:
- Race (select all that apply)
  
  Other
- Parent/Guardian 1
- Name
  
  First NameLast Name
- Relationship to Student
- Job
- Phone
  (999)999-9999
- Email
  example@example.com
- I live with them
- Parent/Guardian 2
- Name
  
  First NameLast Name
- Relationship to Student
- Job
- Phone
  (999)999-9999
- Email
  example@example.com
- I live with them
- Select Highest Level of Education (biological or adoptive parents only):
- Father:
- Mother:
- # of people in my house (including me)
- Check the box that reflects your family’s taxable income. Taxable income is less than gross income/salary.
- All Information is Confiential
- Select all the activities you would Like to participate in
- Academic:
- College/Vo-Tech Prep
- Career
- Please complete the following survey. Your answer will aid in planning workshops at your school. Thank you!
- Educational Goals for this Year (Select all that apply)
  
  Other
- Which subject?
- Plans After High School
  
  Other
- Name of college/vo-tech
- Career interest
- I need financial aid assistance to attend college
- I authorize UA-Little Rock TRIO Talent Search to receive copies of my transcripts, test scores, financial aid awards, school meals verification, and other material necessary to assess post-secondary entry needs and for participation in the program.
- Student Name
  
  First NameLast Name
- Draw signature with the mouse in the box below.
- Student Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- By signing below, I verify all the above information to be true to the best of my knowledge.
- Parent Name
  
  First NameLast Name
- Draw signature with the mouse in the box below.
- Parent Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- I hereby permit the UA-Little Rock TRIO Talent Search Program to use, in whole or in part, student names, photographs, videos, and written extraction of the above named student for the purpose of illustrations or publications including program websites.
- Draw signature with the mouse in the box below.
- Parent Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate

- Please verify that you are human
- Should be Empty: