Coastal Bend College-TS-Application Form

2023-2024 TRIO Talent Search Application

Address: 704 Coyote Trail, Room 143, Alice, TX 78332
Email: dsoliz@coastalbend.edu | Office: (361) 664-2987 ext.3081

Student Information
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
mm-dd-yyyy
Current Age
Gender*

MaleFemale
High School Attending*
Current Grade*
Graduation Year*
Student ID #
May talent search contact your student via cell phone?*

YesNo

Check all portions of the latest STAAR exam you have taken*

	Passed	Not Passed	Not Taken
Reading
Writing
Math
Science
History

What high school academic track are you pursuing?*

Regular HS DiplomaRecommended HS DiplomaDistinguished HS Diploma
What high school academic track are you pursuing?*

Regular HS DiplomaRecommended HS DiplomaDistinguished HS Diploma
Are you in dual enrollment classes?*

YesNo
Do you need assistance with any of the following?*

College class selection and admissions applicationCareer selectionFinancial AidScholarship searchAcademic supportTutoring
Are you at risk of failing?*

YesNo
Do you plan on attending college?*

YesNo
Extenuating personal situation: foster child, orphan, homeless, student with a disability, etc?*

YesNo
Ethnicity: (check all that apply)*

AsianAfrican AmericanHawaiian/Pacific IslanderHispanic/Latino(a)Native American/Alaskan NativeWhite/CaucasianOther
Primary language spoken at home?*
Is student a U.S. citizen?*

YesNo
Is student currently participating in Upward Bound?*

YesNo
Does student work?*

YesNo
If so, how many hours per week?
Does student have children?*

YesNo
Has student been certified as a homeless youth?*

YesNo
Student lives with (Check all that apply)*

FatherMotherGrandparent(s)Other

Parent/Guardian Information
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?*

YesNo
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?*

YesNo
Emergency Contact Name*

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

Parent/Student Consent for Services
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 do not 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.
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)*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

FERPA Consent to Release Student Information
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:*

transcriptdisciplinary recordsrecommendations for employment or admission to other schoolsall recordsOther
The information is to be released for the following purpose

family communications about university experienceemploymentadmission to an educational institutionOther
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*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Name

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

Clear
Date*

MonthDayYear
mm-dd-yyyy