Berea College-UBMS 1

Berea College TRIO Programs

Student Application

Both ParentsMotherFatherGrandparent(s)Legal GuardianOther
MarriedSingleDivorcedSeparatedDeceased (Father)Deceased (Mother)Both Deceased
Parents/Guardian(s) with whom the student lives
Parent/Guardian #1*

First NameLast Name
Relationship*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Email
example@example.com
Occupation
N/A, disabled and/or retired are also acceptable.
Parent/Guardian #2

First NameLast Name
Relationship
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Email
example@example.com
Occupation
N/A, disabled and/or retired are also acceptable.

Other than the student and parents/guardians, please list the name and age of each household member and the relationship to the student.

Rows	Name	Relationship	Age
1
2
3
4
5

If your family has taxable income, please complete the following from your most recent 1040 or 1040-SR federal income tax form.
Form 1040Form 1040SRN/A
Total # of exemptions claimed 1040 & 1040SR*
Taxable Income (Not Adjusted Gross) 1040 Line 15| 1040SR Line 15)*
If no taxable income, please enter zero.
YesNo

Family Information Certification

I certify all family information is accurate to the best of my knowledge. By signing below, I also commit to allow my student to participate in program activities once accepted.

Student Records Release/Authorization

I give the Berea College TRiO program permission to obtain school or agency records of the student listed to
- Determine their academic and/or income eligibility for the program and
- To monitor the status and progress in middle, high school, and postsecondary educational institutions and to determine eligibility for financial aid.
I understand that all records will be kept confidential per federal regulations.

TRiO Program Media Permission Release

During program events and activities TRiO staff members create materials with pictures and images of students participating in programs. Examples of our media projects include flyers, newsletters, radio spots, blogs, program-monitored social media pages and news segments.

By signing below I grant the Berea College Partners for Education Program the right to use my child’s image and images of their work for program promotion.

TRiO programming may occur virtually using online delivery methods such as, but not limited to, Google Classroom, Google Meet, and Zoom. These platforms will allow virtual communications between TRiO staff and your student. Online programming may be recorded for documentation or promotional purposes.

By signing below I grant the Berea College Partners for Education Program the right to communicate virtually with my child and record the communication, as needed.
Parent/Guardian’s Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy