Fayetteville State University-TS 1-Application Form

Fayetteville State University

1200 Murchison Road, Fayetteville, North Carolina 28301 (910) 672-1686 * Fax (910) 672-1854 * ets@uncfsu.edu

STUDENT INFORMATION
STUDENT INFORMATION
Name*

FirstMiddleLast
Student ID*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
(999)999-9999
Secondary Phone*
(999)999-9999
Date of Birth*

MonthDayYear
mm-dd-yyyy
Email Address*
example@example.com
Twitter Name
Facebook Name
Current School*
T-Shirt Size

SMLXLXXL
Current Grade Level*

6789101112
What is your Gender?*

FemaleMale
What is the Primary language spoken in the home?*

EnglishSpanishOther
Are you a*

U.S. CitizenPermanent ResidentOther
Alien Number*
Type N/A if not applicable
Ethnic Background*

Black/ African AmericanAmerican IndianAsian/Pacific IslanderHispanicWhiteMultiple RacesOther
Expected High School Graduation
(example: 12/2021)

Needs Assessment*

	Yes	No
1. I need to get better grades in school
2. I need to develop stronger study skills and habits.
3. I need tutoring
4. I need to learn how to set goals and make better decisions.
5. I need to understand how the courses I am taking relate to my career plans.
6. I need to better understand my interests, abilities and other traits
7. I need to know how to prepare for High School.
8. I need to learn about the correct academic classes that I should be taking in preparation for college.
9. I plan to attend college after High School.
10. I need to learn more about college admissions requirements.
11. I need assistance with financial aid and researching scholarships.
12. My parent(s) currently serve in the military/have served in the military.
13. I need to visit college campuses to explore my options.
14. I need to get involved in positive activities, extra-curricular activities and or clubs or organizations.
15. I have thought about dropping out of school.
16. I receive free/reduce lunch.
17. I am currently sharing housing due to economic hardship or loss of housing, awaiting Foster Care placement, living in a Foster home, residing in a Group home or an emergency/transitional shelter.
18. I am currently enrolled in college courses while in High School (Dual enrollment).

I am currently a participant of the following:*

Upward Bound Math & ScienceUpward BoundFind-A-FriendTalent Search21st Century Community Learning CentersBoys & Girls ClubEducational Opportunity CenterI don't know
Student's Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy

INCOME INFORMATION
INCOME VERIFICATION
Copy of your completed income tax form (1040, 1040EZ, 1040A)

Browse Files

Cancelof
If you DO NOT submit a copy of your completed income tax form (1040, 1040EZ, 1040A), you will need to complete the information below, which serves as a verification of your family income for last year.

*Taxable Income*: This information is located on tax forms (1040-line 43; 1040A-line 27; 1040EZ-line 6)
What is your family’s Taxable Income for last year?*
DO NOT USE YOUR ADJUSTED GROSS INCOME.
How many people are living in your household?*
Do you receive Public Assistance?*

AFDCFood StampsSocial SecurityDisabilityNone
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy

RELEASE FORM
Fayetteville State University
Talent Search/21st Century Community Learning Centers Program
Release Form
Student's Name*

First NameLast Name
Current School*
Student School ID Number*
The information requested on this form will be utilized to assist us in providing 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 offices, social workers, etc. ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA).

School Records
As the parent and/or legal guardian of ____________________________, I grant Talent Search/21st Century Community Learning Centers Programs permission to obtain school records, transcripts, standardized test scores (EOC/EOG/SAT/ PSAT/ACT /PLAN) grade reports, test results, and financial aid transcripts from the secondary school and college my child is attending until he/she graduates from college or for 6 years after he/she graduates from high school, according to the terms of the federal Talent Search grant. I will also permit Talent Search/21st Century Community Learning Centers staff to speak with teachers, counselors, and other school 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/21st Century Community Learning CentersPrograms. I authorize the Programs to access or release copies of my child’s academic transcripts, test scores, college admissions enrollment, and financial aid information that are necessary to assist my son/daughter in achieving his/here educational goals.*
Student Name
Waiver of Liability
As parent and legal guardian of the above-mentioned student, I authorize and permit my child to participate in field trips, activities, and events offered by the Talent Search/21st Century Community Learning Centers Programs. I understand that my child may be leaving his/her school campus or Fayetteville State University and may be transported by the TalentSearch/21st CCLC staff of Fayetteville State University. I agree that Fayetteville State University, Talent Search, 21st Century Community Learning Centers Program, Cumberland, Hoke and Robeson Counties and anyone associated withFayetteville State University will not be held liable for any loss, injury, or death related to any field trips, or events. Further,I agree to hold Fayetteville State University, Talent Search, 21st Century Community Learning Centers Program, AdvisoryCommittee members, officers, staff, and volunteers, the Cumberland, Hoke and Robeson County School systems harmless from any claims whatsoever occasioned in any of the situations that I have agreed, that Talent Search/21st Century Community Learning Centers Program at Fayetteville State University shall not be held liable.In the event that my child, _________________________ is involved in a medical emergency, I authorize the TalentSearch/21st Century Community Learning Centers Program 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.*
Student Name
Insurance Name and Number*
Medicaid Card Number*
Emergency Contacts
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
(999)999-9999
Relationship to Student*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
(999)999-9999
Relationship to Student*
Media Release
Periodically, students participating in the Programs events may be photographed, filmed, or interviewed. As the parent and/or legal guardian of _______________________, I grant permission for my child to participate in photographs , films, or interviews as they pertain to the Talent Search/21st Century Community Learning Centers Programs and I understand that such pictures, film, or interviews may be used to promote or publicize the program events or demonstrate how federal funds are being used to assist students.*

First NameLast Name
Student Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy

VIRTUAL CONSENT FORM
Fayetteville State University
Talent Search Program
Virtual Consent Form

I hereby consent to the Fayetteville State University TRIO Talent Search Programs collection, use, and/or disclosure of information about my child through the program registration process and other manual and/or electronic procedures of the FSU TRIO Talent Search Program or associated course providers. I understand that my child is registering for a virtual program, and that the information collected is needed for the program registration.

This consent form covers all forms of distance learning courses, included but not limited to satellite courses, video courses, and web-based courses. Your child’s image may be transmitted during video portions of distance learning and on-line courses/activities.

The information supplied to the Talent Search Program may include, but not be limited to: student name, address, phone number, age, gender, school name, student grade in school, student email address, student progress and grade in course/s.

The Fayetteville State University TRIO Talent Search Program has taken this step in order to be in compliance with federal legislation for child protection, including The Family Educational Rights and Privacy Act (FERPA - http://www.ed.gov/offices/OM/ferpa.html) and the Children’s Online Privacy Protection Act (COPPA http://www.ftc.gov/os/1999/9910/64fr59888.htm).

Since the on-line courses/activities are web-based, content accessed from home or elsewhere outside the program could put the student in contact with objectionable materials via the World Wide Web. It is the responsibility of the parent/guardian of the student to restrict any access to materials deemed inappropriate by the parent/guardian.
Student's Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Parent's Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy