Fayetteville State University-TS 2-Application Form

Fayetteville State University
1200 Murchison Road
Fayetteville, North Carolina 28301
(910) 672-1312 * Fax (910) 672-1854 * talentsearch@uncfsu.edu

Student Information
Name of Student*

First NameMiddle NameLast Name
Student ID
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / 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*

9101112
What is your gender?*

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

EnglishSpanishOther
Are you a*

U.S. CitizenPermanent ResidentOther
Alien Number
Ethnic Background*

Black/African AmericanAmerican IndianAsian/Pacific IslanderHispanicWhiteMultiple RacesOther
Expected High School Graduation*

MonthDayYear
Date

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 (specify below)
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 need tutoring in

sciencemathEnglishhistoryOther
I am currently a participant in 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

MonthDayYear
mm-dd-yyyy

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 {main_name}, 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 Centers Programs. 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/her educational goals.

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 Talent Search/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 with Fayetteville 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, Advisory Committee 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, {main_name} is involved in a medical emergency, I authorize the Talent Search/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.
Insurance Name and Number
Medicaid Card Number
Emergency Contacts
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / 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 {main_name}, 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.
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy