Tehama County Department Of Education-TS-Application Form

Tehama County Department of Education
Bridge to College and Career Department
Talent Search (TS) Program Application

Please be sure to Complete, Sign, and Date the ENTIRE application by the Student and Parent/Legal Guardian(s) Incomplete applications to the program will delay the process for participation in the TS Program.

Parent or Legal Guardian Information
Student Resides with *

Both Parents Mother Only Father Only Parent and Stepparent Grandparents Foster Parent(s) or Legal Guardian(s)
Parent/Legal Guardian #1
Name *

First Name Last Name
Relationship *
Work/Employment *
Cell Phone *
(999)999-9999
Home or Work Phone *
(999)999-9999
Email *
example@example.com
Parent/Legal Guardian #2
Name

First Name Last Name
Relationship
Work/Employment
Cell Phone
(999)999-9999
Home or Work Phone
(999)999-9999
Email
example@example.com
What is the primary language used in the home? *

List ALL persons currently living in the student’s home (First line should be the student applying on this application; additional names can be on separate page)

Name

Age

Relationship to Student

Name of School or Job

*Funding is provided by the US Department of Education and requires specific documentation of household income level and educational background level(s) for enrollment into the TS Program. The information is protected by the Family Educational Rights and Privacy Act (FERPA). All student documentation will be shredded for confidentiality, who are found ineligible to participate in the TS program from the Federal guidelines and regulations.
The Information collected is ONLY used to determine the student’s eligibility to participate in the TS program.
Parent/Legal Guardian Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy
**Note: If you are a Foster or Homeless Youth, You Are NOT required to complete Family Eligibility Criteria below and complete the remaining sections of the application only.

Family Eligibility Criteria
Number of People in the Household *
Family Income Status.Taxable Income (not Adjusted Gross Income) see 1040 tax form, line 43; or 1040A tax form, line 27; or 1040 EZ tax form, line 6. *

$0-$18,735 $18,736-$25,365 $25,366-$31,995 $31,996-$38,625 $38,626-$45,255 $45,256-$51,885 $51,886-$58,515 $58,516-$65,145 $65,146 or above Did Not File Taxes
Biological Parent, Adoptive Parent or Legal Guardian Education Levels
Biological/Adoptive Father or Male Legal Guardian – Please check highest level of education completed *

Formal Education Elementary School Jr. High High School Grad GED/HS Diploma Equivalent Associate’s Degree Bachelor’s Degree Master’s Degree Post-Graduate Degree or higher

If Biological/Adoptive Father or Male Legal Guardian earned a four year or higher degree, please list degree(s) earned, year, and institution where earned

Degree or Certification Type

Year Earned

College/University Name

Biological/Adoptive Mother or Female Legal Guardian – Please check highest level of education completed *

Formal Education Elementary School Jr. High High School Grad GED/HS Diploma Equivalent Associate’s Degree Bachelor’s Degree Master’s Degree Post-Graduate Degree or higher

If Biological/Adoptive Mother or Female Legal Guardian earned a four year or higher degree, please list degree(s) earned, year, and institution where earned

Degree or Certification Type

Year Earned

College/University Name

Parent/Legal Guardian Authorization
VOLUNTARY EXCURSION/FIELD TRIP NOTICE AND MEDICAL AUTHORIZATION – MINOR
Medical Release: In the event of illness or injury, I do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgement of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.

As stated in California Education Code Section 35330, I understand that I waive all claims against the Tehama County Department of Education, its officers, agents and employees for any injury, accident, illness, or death occurring during or by reason of this field trip or excursion, including acts of negligence by the Tehama County Department of Education, its officers, agents or employees.

Mandated Reporting Release: Most information shared between participants and Program Representatives is secured and completely confidential. Please be aware that a few exceptions will apply when/if information is shared regarding abuse (physical, mental, or sexual) and/or harm to oneself or others must be report by law to the appropriate individuals.

The California Child Abuse and Neglect Reporting ACT (CANRA) can be found in California Penal Code Sections 11164 - 11174.3. Under CANRA, mandatory reports are legally mandated to report the list below, is not limited but includes the following individuals who must report abuse or neglect: Clergy Members and custodian of records for clergy members; Child Care Providers; Educator or any local district, county, or state education employees, Law Enforcement; Medical Providers; Mental Health Professionals; and Commercial Film and Photographic Print Processors.

Permission to Access School Records: I hereby give TCDE/BCC Program staff permission to have access to grades, progress reports, school transcripts, and updated contact information from the school administration. I authorize TCDE/BCC to assist with my child’s college admission, financial aid application (FAFSA), acceptance status, and award letter(s) to any and all colleges/universities they choose to apply to after they graduate from high school.

Participation: I give my permission for my child to participate in TCDE/BCC (TS) activities; I agree to encourage my child to do well in middle and high school, as well as pursue post-secondary education based on their career interests. Lack of participation and/or non-attendance at any group or individual meetings for TS may result in the student being dropped from the TS program for the academic year or remaining academic year, as noticed by the site Program Specialist of lack or non-attendance from students. Please have students notify the site Program Specialist or the BCC office know if you are
moving out of the service or school site area boundaries.

I fully understand that participants are to abide by all rules and regulations governing conduct during the trip. Any violation of these rules and regulations may result in that individual being sent home at the expense of his/her parent/guardian.
Parent/Legal Guardian Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy

Student Contract - Complete, Sign, and Date Section Below
I, _______________ agree to the following of the TCDE - BCC/TS Program requirements outlined below, that if I am accepted into the TS program, I will completely and fully follow the direction of the Program Specialist from TS while I am participating in this program:

1. Strive to continually improve my school grades, attendance, and participation in the TS program and maintain no less than a 2.0 GPA
2. Follow all the education and career recommendations of my Program Specialist and/or Program Support contact(s) to attend any recommended tutoring sessions when my grades are not meeting appropriate standards or I need support
3. Attend all TS workshops, individual appointments, and activities with my Program Specialist and/or Program Support contact(s), unless there is a conflict with other academic or personal obligations/responsibilities and notify in advance the Program Specialist and/or Program Support contact(s) of those conflicts
4. Remain an active participant in the BCC – TS Program through my high school graduation
5. Understanding that Lack of participation or attending any individual and/or group workshops MAY result in my being dropped from the BCC – TS program
6. Follow the instructions and complete required documentation while participating in the BCC – TS activities and traveling on official BCC – TS approved field trips
7. Communicate with Program Specialist and/or Program Support contact(s) about my educational and personal career goals
8. Graduate from high school
9. Make every attempt to apply, attend, and complete a post-secondary education program after high school graduation
10. Provide follow-up information to the TCDE/BCC – TS Program concerning my success in obtaining a post-secondary degree, career achievements, and/or military achievements.

This is not a complete or whole list of requirements of students of the TS program, as the list can be edited, revised, or add additional requirements as needed by local, state, and federal laws and regulations apply. Please see the Bridge to College and Career Student/Parent Program Handbook for more requirements, eligibility, and participation rules.

By signing my name on the signature line below, I certify to the best of my ability that each response within the application is true and complete to the best of my knowledge. It all indicates that I have read, reviewed, and understand the requirement material and questions asked above.
Student Name *

First Name Last Name
Student Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy