George C. Wallace Community College-Hance-TS

PARTICIPANT APPLICATION

Please type or print in blue or black ink. (Please do NOT use white-out!)

STEP 1:
Student, please answer the following questions about yourself.
a. What is your name?*

First NameMiddle InitialLast Name
b. What is your mailing address?*

Street Address

Apt. #

CityState

ZIP
c. What is your home phone number?
(999)999-9999
d. What is your cell phone number?
(999)999-9999
e. What is your parents or guardians’ cell phone number?
(999)999-9999
Whose phone number?

MotherFather
f. What is your personal e-mail?, not school issued e-mail address.*
example@example.com
Parent or Guardian Name

First NameLast Name
g. What is your parent or guardian's email address?
example@example.com

STEP 3:
Student, please answer the following question about yourself.
a. Are you a U.S. citizen?*

YESNO, but I am a Permanent Resident.NO, I am not a U.S.citizen, and I am not a permanent resident.
My Permanent Resident Alien Number is*

STEP 4:
Student, please answer the following questions about your parents and about yourself.
a. Has your mother received/earned a baccalaureate degree?*

YESNO
YES from*
b. Has your father received/earned a baccalaureate degree?*

YESNO
YES from*
c. Which parent do you regularly live with and receive support from? (Please check only one box.)*

Both Mother and FatherMother onlyNeither Mother nor FatherFather only
Talent Search is funded by the Dept. of Education TRIO programs P044A210756. No student shall be discriminated against on the basis of any impermissible criterion or characteristic including, but not limited to, race, color, national origin, religion, marital status, disability, gender, age or any other protected class as defined by federal or state law. Institutions must publish their policies regarding nondiscrimination.

STEP 7:
You (the student) must read the following statement and then sign and date below it. If you (the student) are less than 24 years old and answered NO to all the questions in STEP 5, your parent or legal guardian must also read the following statement and then sign and date below it.
By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of the student’s official academic records to the Talent Search Dept.of Wallace State Community College understanding that the information in these records will be used only to assess the student’s need for TRIO program services, discern the student’s educational progress, evaluate the effectiveness of TRIO program activities, and fulfill TRIO program-reporting requirements. Finally, I authorize Talent Search of WSCC to use the student’s name, statements and likeness, without charge, for promotional purposes in WSCC publications, advertising, video, and other formats. My child has permission to participate in field trips planned for and supervised by TALENT SEARCH. Further, should my son/daughter require medical attention and/or care while participating in TALENT SEARCH, I give my consent to medical examination and necessary treatment as may seem necessary by the attending physician. This consent shall remain effective so long as my son/daughter is a participant in Talent Search. Should an emergency arise, staff will attempt to provide care as needed.
Student’s Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Signature of Student’s Parent or Legal Guardian*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Size of Family	Taxable Income
1	$22,590
2	$30,660
3	$38,730
4	$46,800
5	$54,870
6	$62,940
7	$71,010
8	$79,080