Davidson County Community College-TS

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TRiO Talent Search Application 2020-2021

Family Information
Check one of the following *

Single Parent Household Two Parent Household
Number of immediate family members living in household *
Who do you live with?

Live with mother/guardian Live with father/guardian Both
If you selected "Other", please explain
Parent/Guardian 1 Name

First Name Last Name
Parent/Guardian 1 Email
example@example.com
Relationship to Student
Parent/Guardian 2 Name

First Name Last Name
Parent/Guardian 2 Email
example@example.com
Relationship to Student

Parent/Guardian 1 Education *

Yes

High School Grad

Two Year College Grad

Four Year College Grad

Child's Medical History
Does your child have any allergies? *

Yes No
If yes, please list *
Does your child have a physical impairment, medical condition or disability? *

Yes No
If yes, please list *
Is your child taking any type of prescription medication? *

Yes No
If yes, please list *
I certify that all the information above is correct and true to the best of my knowledge. I understand the information is confidential and will only be used for verification for this program.
Parent/Guardian Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy

Release Form
Davidson County Community College TRiO Talent Search Program Release Form
Student's Name

First Name Last Name
School
The information requested on this form will be utilized to assist us in providing free services for your child. To provide the most effective services, we may need to obtain information from several sources, such as high schools, colleges, testing agencies, counselors, admissions and financial aid officers, social workers, etc. All information received will be kept confidential in compliance with the Family Educational Rights and Privacy Act.

I. School Records
As the parent and/or legal guardian of {studentsName}, I grant Talent Search permission to obtain school records, progress reports, and test results from the secondary school my child is attending. I will also permit Talent Search staff to speak with teachers, counselors, and other administrators at my child’s school in order to obtain and exchange information as part of the services my child will receive from the Talent Search Program. I authorize the Talent Search Program to access copies of my child’s progress reports and/or test scores that are necessary to assist my son/daughter in achieving his/her educational goals.

II. Waiver of Liability
As parent and legal guardian of {studentsName}, I authorize and permit my child to participate in field trips, activities, and events offered by the Talent Search Program. I understand that my child may be leaving his/her school campus or Davidson County Community College and may be transported by the Talent Search staff of Davidson County Community College. I agree that the Lexington City Board of Education, the Thomasville City Board of Education, Davidson County Community College, and Talent Search staff, or anyone associated with the Lexington City Board of Education, the Thomasville City Board of Education, and Davidson County Community College will not be held liable for any loss, injury, or death related to any field trips or events. Further, I agree to hold the Lexington City Board of Education, the Thomasville City Board of Education, Davidson County Community College, Talent Search staff, advisory committee members, officers, staff, and volunteers, harmless from any claims whatsoever occasioned in any of the situations that I have agreed, that Talent Search and Davidson County Community College, the Lexington City Board of Education and the Thomasville City Board of Education shall not be held liable.

III. Medical Release
In the event that my child, {studentsName}, is involved in a medical emergency, I authorize the Talent Search staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc.) if they are unable to contact me for verbal authorization.
Insurance Name
Insurance Number
(999)999-9999
Medicaid Card Number
IV. Emergency Contacts
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
(999)999-9999
Email
example@example.com
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
(999)999-9999
Email
example@example.com
V. Media Release
Periodically, students participating in the Talent Search Program events may be photographed, filmed, or interviewed. As the parent and/or legal guardian of {studentsName}, I grant permission for my child to participate in photographs, films, or interviews as they pertain to Talent Search and I understand that such pictures, film, or interviews may be used to promote or publicize the Talent Search events or demonstrate how federal funds are being used to assist students.
VI.

I, {parentguardianName},authorize DCCC TRIO Talent Search to send communication via email, text message, school messenger, REMIND App to my email, students email, cell phone, student cell phone, or home phone. I understand that text messaging rates may apply to any text messages received. I also understand that I or DCCC TRIO Talent Search may revoke this permission in writing at any time. I agree not to hold DCCC TRIO Talent Search liable for any electronic messaging charges or fees generated by this service. I further agree that in the event emails, cell phone and other information changes, that I will inform DCCC TRIO Talent Search.
Student Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy
Parent/Guardian Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy
Parent/Guardian Name

First Name Last Name