North Shore Community College-TS

LYNN TRIO TALENT SEARCH

Program Application

Serving eligible Lynn Public School students attending: Lynn Classical High School, Lynn English High School, Lynn Vocational Technical Institute, Fecteau - Leary Alternative High School

Talent Search Advisors are located in the LCHS, LEHS, LVTI Guidance Departments

Main Office Location: 300 Broad Street, LW158, Lynn, MA

Mailing Address: Talent Search at NSCC, Box 3340, Danvers, 01923

Phone: 781-477-2190 FAX: 781-477-2112

Program Overview
Dear Parent or Guardian,

Your child is interested in joining the TRIO/Talent Search (TS) program, a free program that will help them complete high school and continue on to higher education. The services are free and include:

·      Career Exploration

·      Math/English/Science Tutoring

·      College Visits

·      SAT/ACT/ACCUPLACER Preparation

·      Information About Higher Education

·      Assistance with College Admissions Applications

·      Assistance with Financial Aid Applications

To receive these services, this application must be completed and signed by you. The information required includes family income information, parent’s educational status, student’s citizenship status and permission for TS to have access to the student’s school records. All information is kept confidential and secure.

The most difficult question to answer is: “What is your taxable income as it appears on your most recent tax form?” If you did not have to file taxes, the answer is “0”. Taxable income is not the same as adjusted gross income or the total amount of wages earned.

We look forward to helping your child achieve their dream of continuing onto higher education! If you have any questions or concerns, please call our office at 781-477-2190.

Thank you!

TRIO Talent Search Staff

Sarah Coffee, LCHS and LVTI
Indira Leisba, LEHS and LVTI

Family Information
FAMILY INFORMATION

To be completed by parent or guardian.

The Talent Search Program is required by the U.S. Department of Education to collect family income and other family information from all participants. Applications will not be reviewed until this information is complete. All information is kept confidential.

List all people living in your home, including the student:*

	First Name	Last Name	Age	Relationship to Student	Highest Grade Completed
1.
2.
3.
4.
5.
6.
7.

Has the student’s mother earned a Bachelor’s Degree from a 4-year university or college in the U.S.?*

YesNoUnknown
Name of school*
Has the student’s father earned a Bachelor’s Degree from a 4-year university or college in the U.S.?*

YesNoUnknown
Name of school*
FAMILY INCOME
Did the family file a Federal Income Tax Return last year?*

YesNo
Using last year’s IRS Form 1040, line 15, select the line that indicates the taxable income for the student’s family: (if the box is blank, then taxable income = 0.)*

$0 - $23,475$39,976 - $48,225$64,726 - $72,975$23,476 - $31,725$48,226 - $56,475$72,976 - $81,225$31,726 - $39,975$56,476 - $64,725$81,226 and above
Parent/Guardian Income & Support Sources: Please select all income and benefit the student’s family receives*

Salary/WagesSSDISocial SecuritySNAP/Food StampsTANF/WelfareUnemployment BenefitsVeteran’s BenefitsHousing VoucherChild SupportRetirement/Pension
PARENT/GUARDIAN CERTIFICATION AND SIGNATURE

I verify that by signing this document and submitting the requested documentation that the information which I have provided is accurate to the best of my knowledge. I understand that this information will be held in complete confidence by the Talent Search Program at North Shore Community College.
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Cell Phone*
(999)999-9999
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy

Consent and Liability Releases
PARENT/GUARDIAN CONSENT AND LIABILITY RELEASE
I, __________________________________*

Parent First NameParent Last Name
give my son/daughter/ward, _______________________________________, permission to participate in the North Shore Community College (NSCC) Talent Search (TS) Program.*

Student First NameStudent Last Name
I also absolve NSCC, the Talent Search Program, their personnel and the Lynn Public School District of any liabilities and claims arising from my child’s participation, and attendance in the program, including travel to and from events and activities. Further:

Medical release: I consent to and authorize emergency and non-emergency medical care to be provided to my child in the unlikely event of a health problem, emergency or injury occurring during my child’s attendance in the TS program. I give my consent and authorization to appropriate TS staff to use their judgment in seeking medical care for my son or daughter. I understand that an attempt will be made to contact me in the event that emergency medical care is needed.

Mandated reporting: I give permission for the TS program to obtain the academic records/information for the above named student throughout their high school career and for six years following their graduation to allow for annual tracking of TS participant’s education as is required by Federal Department of Education regulations to evaluate the TS Program. I understand that this information will be held in compliance with FERPA and other applicable state laws and will only be accessible to appropriate program staff and Department of Education personnel.
Parent/Guardian's Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Consents/releases remain in effect until written revocation is received by the TS program at NSCC, 1 Ferncroft Road, Danvers, MA 01923.
PARENT/GUARDIAN MEDIA RELEASE
I____________give permission.....

First NameLast Name
I (DO/DO NOT as indicated below) give permission for the Talent Search program and affiliates to use pictures, video recordings, and audio recordings of the above-named student for all program-related purposes, including for publication on social media, online, in print, and other media.*

DODO NOT
Parent/Guardian's Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Consents remain in effect until written revocation is received by the TS program at NSCC, 1 Ferncroft Road, Danvers, MA 01923

STUDENT CONSENT AND PARTICIPATION AGREEMENT
I, _______________________________________, understand that by participating in the Talent Search Program I will be participating in a federally funded TRIO program designed to help me graduate high school and continue on to post-secondary education.*

Student First NameStudent Last Name
Accordingly, I understand that I am subject to the program policies and procedures and if accepted into the program I agree to the following:
- To strive to attain personal, academic, and career goals that I set for myself.
- To treat myself, other students, and staff with respect, and be a positive representative of the program.
- To attend school every day.
- To periodically/as scheduled meet with my TRIO advisor
- To attend relevant workshops, and to fully participate in the program.
- To demonstrate model behavior in and out of school, including while on any and all field trips.
- To share academic information with TS staff in order to assist in planning and tracking.
- To have fun and do my best!
I have read the above rules and promise to uphold them and to be a good representative of my school and the TS program. I understand that any serious breach of behavior may result in dismissal from the program.
Student's Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Additionally, I understand that in order to facilitate successful participation in the program the TS staff will need access to my academic records throughout my participation in the program and my post-secondary enrollment information after high school graduation for the purpose of data reporting. I understand this consent will remain in effect until its written revocation is received by the TS program at NSCC, 1 Ferncroft Road, Danvers, MA 01923.
Student's Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Consents remain in effect until written revocation is received by the TS program at NSCC, 1 Ferncroft Road, Danvers, MA 01923.

Refer-a-Friend
Please indicate the name of a friend or relative that might also be interested in learning about or joining Talent Search:
Name:

First NameLast Name
Contact Number:
(999)999-9999
Contact Email:
example@example.com
If you were referred by a friend, please enter their name here:

First NameLast Name