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 Name Middle Initial Last Name
b. What is your mailing address? *

Street Address

Apt. #

City State

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’ cell phone number?
(999)999-9999
Whose phone number?

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

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

STEP 2:
Student, please answer the following questions about yourself.
a. What is the name of your school? *
b. What grade are you in? *
c. What is your social security number? *
999-99-9999
d. What is your birthdate? *

Month Day Year
mm-dd-yyyy
e. Are you Hispanic or Latino? *

Yes No
f. What is your race? (Please check all boxes that describe you.) *

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White
g. What is your gender? *

Female Male

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

YES NO, but I am a Permanent Resident. NO; I am not a U.S.citizen, and I am not apermanent 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? *

YES NO
YES from *
b. Has your father received/earned a baccalaureate degree? *

YES NO
YES from *
c. Which parent do you regularly live with and receive support from? (Please check only one box.) *

Both Mother and Father Mother only Neither Mother nor Father Father only
Talent Search is funded by the Dept. of Education TRIO programs P044A160663 No student shall be discriminated against on the basis of any impermissible criterion or charachteristic including ,but not limited to, race, color,nationa 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 6:
You (the student) must answer the following questions about yourself if you are at least 24 years old or you answered YES to any question in STEP 5. Your parent(s) must answer the following questions about themselves if you are less than 24 years old and you answered NO to all questions in STEP 5.
a. What is the total number of persons (including you) in your family unit? *
b. What was your family’s taxable (not total) income from the last calendar year? (Please check only one box. Then, provide the requested income information.) *

My family’s taxable (not total) income from the last calendar year was: Note: Taxable income can be found on the federal income tax return.On IRS Form 1040, see line 10. My family did not file a federal income tax return for the last calendar year. My family had no taxable income during the last calendar year
My family’s taxable (not total) income from the last calendar year was :Note: Taxable income can be found on the federal income tax return.On IRS Form 1040, see line 10. *
My family’s total income from the last calendar year was: *

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.
Student’s Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy
Signature of Student’s Parent or Legal Guardian *

Clear
Date *

Month Day Year
mm-dd-yyyy