Coastal Bend College-TS

TRIO Talent Search Application

Address: 3800 Charco Road, Beeville, TX 78102

Email: trioets@coastalbend.edu

Office: (361) 354-2706

COASTAL BEND COLLEGE DOES NOT DISCRIMINATE ON THE BASIS OF RACE, CREED, COLOR, NATIONAL ORIGIN, SEX, AGE, OR DISABILITY. TALENT SEARCH IS A 100% FEDERALLY FUNDED PROGRAM.

Student Information
Student Name*

First NameMiddle NameLast Name
Social Security #*
Mailing Address*

Address

Street Address Line 2

CityState

Zip Code
Parent Cell Phone
(999)999-9999
Student Cell Phone*
(999)999-9999
Student's Personal Email*
example@example.com
Birthdate*

MonthDayYear
mm-dd-yyyy
Current Age
Gender*

MaleFemale
High School Attending*
High School Attending*

AC Jones HSGeorge West HSKarnes City HSKenedy HSOdem HSRefugio HSRunge HSTaft HSThree Rivers HSWoodsboro HSOther
Current Grade*
Graduation Year*
Student ID #
May Talent Search contact your student's cell via text message?*

YesNo

Check all portions of the latest STAAR Exam you have taken*

	Passed	Not Passed	Not Taken
Reading
Writing
Math
Science
History

What high school academic track are you pursuing?*

Regular HS diplomaRecommended HS diplomaDistinguished HS diploma
Are you in dual enrollment classes?*

YesNo
Do you need assistance with any of the following?*

College class selection and admissions applicationCareer selectionFinancial AidScholarship searchAcademic supportTutoring
Are you at risk of failing?*

YesNo
Do you plan on attending college?*

YesNo
Extenuating personal situation: foster child, orphan, homeless, student has children, student with a disability, etc?*

YesNo
Ethnicity (Check all that apply)*

AsianHispanic/Latino(a)American IndianAfrican AmericanNative American/Alaska NativeHawaiian/Pacific IslanderWhite/CaucasianOther
Primary language spoken at home? *
Is student a U.S. Citizen?*

YesNo
Is student currently participating in Upward Bound?*

YesNo
Does student work?*

YesNo
If so, how many hours per week?
Does student have children?*

YesNo
Has student been certified as a homeless youth?*

YesNo
Student lives with*

FatherMotherGrandparent(s)Other

Parent/Guardian Information
Mother/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Same as address listed above

Same as address listed above
Contact Number
(999)999-9999
Email
example@example.com
Job Position
Did you graduate with a bachelors or higher?*

YesNo
Father/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Same as address listed above

Same as address listed above
Contact Number
(999)999-9999
Email
example@example.com
Job Position
Did you graduate with a bachelors or higher?*

YesNo
Emergency Contact Name*

First NameLast Name
Relationship to applicant
Emergency Contact Number*
(999)999-9999

Parent/Student Consent for Services
CONSENT FOR SERVICES/TREATMENT:
I understand Talent Search services including but not limited to: academic advising, tutoring referrals, cultural enrichment activities, career and college exploration; will be provided as needed. Services are provided by Talent Search (TS) staff (advisors, volunteers, mentors, tutors, and teachers), and are designed to help students achieve their academic and personal goals. These services are provided free of charge and at the student’s will.

I authorize diagnostic medical and/or surgical treatment on my child as may be deemed medically necessary in order to assure the safety of my child. It is distinctly agreed and understood that the attending physician and appropriate staff shall not be responsible in any way for any consequences from said diagnostic, medical and/or surgical treatment and is fully released from any and all claims and demands whatsoever which arise, grow out of or be incident to such diagnosis, treatment or surgery insofar as the law allows provided that these services are performed with ordinary care and the best of their ability. Talent Search does not provide payment for medical expenses.

BEHAVIOR AGREEMENT:
I understand that the rules I am held responsible to at my school campus are the same rules that apply during any event/activity with the TRIO Talent Search Program. Fighting, obscene language, threatening others, theft and damaging property is strictly prohibited. Alcoholic beverages, controlled substances, and weapons are strictly prohibited. Appropriate clothing and, when swimming, appropriate swimwear to be worn at all times. Students must show respect for TRIO Talent Search staff at all times. If any rule is broken during an event/trip I understand, if it becomes necessary, the Talent Search staff will call my parents and they will be required to pick me up IMMEDIATELY, at their own expense. I also understand that failure to abide by any of the recognized rules may result in my dismissal from the Talent Search Program.
IMAGE (MEDIA) RELEASE: (CHECK ONE)*

I do give talent search permission to use my child’s picture/image and/or accomplishments as a result of my child’s participation in the program. The images/pictures may be used on program brochures, newsletters, flyers, or be published on the program/college website to activities and participation. I release any claims against coastal bend college, the talent search program and/or its staff for any damages, awards, claims or liabilities, which may arise from any unauthorized or copyright violations of my child’s image, picture, or work.I do not give talent search permission to use my child’s picture/image and/or accomplishments as a result of my child’s participation in the program.
I consent and verify the information provided above is true to the best of my knowledge.
Parent/Guardian Signature (If over 18 years old, you can sign for yourself)*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Signature *

Clear
Date*

MonthDayYear
mm-dd-yyyy