Coastal Bend College-TS-Application Form

2024-2025 TRIO Talent Search Application

Address: 704 Coyote Trail, Room 107, Alice, TX 78332
Email: talentsearchalice@coastalbend.edu | Office: (361) 664-2981 ext.3081

Student Name

First NameMiddle NameLast Name
Social Security #
999-99-9999
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Cell Phone
(999)999-9999
Student Cell Phone
(999)999-9999
Student Email
example@example.com
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Current Age
Gender
High School Attending
Current Grade
Graduation Year
Student ID #
May talent search contact your student via cell phone?

Check all portions of the latest STAAR exam you have taken

Rows	Passed	Not Passed	Not Taken
Reading
Writing
Math
Science
History

What high school academic track are you pursuing?
What high school academic track are you pursuing?
Are you in dual enrollment classes?
Do you need assistance with any of the following?
Are you at risk of failing?
Do you plan on attending college?
Extenuating personal situation: foster child, orphan, homeless, student with a disability, etc?
Ethnicity: (check all that apply)

Other
Primary language spoken at home?
Is student a U.S. citizen?
Is student currently participating in Upward Bound?
Does student work?
If so, how many hours per week?
Does student have children?
Has student been certified as a homeless youth?
Student lives with (Check all that apply)

Other

Mother/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
(999)999-9999
Email
example@example.com
Employer and Job Position
Did you graduate from a 4-year college?
Father/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
(999)999-9999
Email
example@example.com
Employer and Job Position
Did you graduate from a 4-year college?
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
(999)999-9999

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 with the Talent Search Program. If any rule is broken I understand if it becomes necessary, the TS staff will call my parents and they will be required to pick me up IMMEDIATELY. I also understand that failure to abide by any of the recognized rules may result in my dismissal from the Coastal Bend College 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 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)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy

TO: Name of High School
Please provide information from the educational records of
FROM: Name of Student requesting the release of educational records

First NameLast Name
(Note: this Consent does not cover medical records held solely by Student Health Services or the Counseling Center – contact those offices for consent forms.)
The only type of information that is to be released under this consent is:

Other
The information is to be released for the following purpose

Other
I understand the information may be released orally or in the form of copies of written records, as preferred by the requester. I have a right to inspect any written records released pursuant to this Consent (except for parents’ financial records and certain letters of recommendation for which the student waived inspection rights). I understand I may revoke this Consent upon providing written notice to TRIO Talent Search. I further understand that until this revocation is made, this consent shall remain in effect and my educational records will continue to be provided to TRIO Talent Search for the specific purpose described above
Student Name

First NameLast Name
Student ID
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Parent Name

First NameLast Name
Parent/Guardian Signature (If over 18 years old, you can sign for yourself)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy