Central Michigan University-TS-Application Form

Central Michigan University
TRIO Talent Search
Serving Detroit Schools Since 1999

STUDENT APPLICATION

Talent Search Detroit Program (TSD) is a U.S. Department of Education federally funded program hosted by Central Michigan University (NO COST to the participant). The program serves 500 students in grades 6-12 in Southwest Detroit who attend a target school: Western International High School, Academy of the Americas, Hope of Detroit Academy High School, Clippert Middle School and Munger Middle School. The program provides academic enrichment, career exploration and financial literacy to its participants and encourages them to graduate from high school and continue on and complete their postsecondary education.

In addition, the program offers SAT preparation, mentoring, educational field trips, cultural events, college tours, summer programs and referral services. Students may remain in the program until they graduate from a target high school.

Criteria for Admission Includes:
1. Income Eligible and/or*
2. First-Generation College Graduate (neither parent graduated from a four-year college)
3. Academic Need and Desire & Motivation to Succeed
4. Ability to Participate in program activities
  *1/3 of students can be either income eligible OR first-generation college students
Program Required Documentation, but not limited to (submit ALL documentation):
- Student Birth Certificate
- Student Recent Report Card or Progress Report
- Student school or state ID
- Parent/Guardian’s most recent 1040 /1040A tax return or Signed income verification form.
- Application requires parent signatures and/or student signature
If you have any questions, please contact the CMU TRIO office call 989-774-7068 or 989-774-7080 or email CMUTalentSearch@gmail.com. Once a student’s completed application and ALL documents are received a review and acceptance will be determined. All eligible applicants will receive notification via mail. Thank you for your interest in the TRIO Talent Search Program!

Emergency Contact Information - Not Parent or Guardian
Person to Notify in Absence of Parent/Guardian*

First NameLast Name
Person's Telephone Number*
(999)999-9999
Relationship to student*

Agreements
Program Participation

I pledge to put forth my very best effort to learn and achieve. I will strive to be present for all program activities during the Academic Year and will participate in the Summer Component. Activities include, but are not limited to Student workshops, Student Meetings, College Goal Saturday, Field Trips, College Tours, Conferences, Grade Meetings.
- I agree to maintain a 2.5 GPA, if my GPA falls below a 2.5 I will be required to attend tutoring.
- If my attendance falls below 70% an TS staff member will contact student and parent/guardian regarding eligibility status.
- If I have difficulty attending the program, I will notify an TS staff member immediately.
- I will adhere to program dress code during TS activities/events.
- I will adhere to the program and school guidelines. If I do not, I may be dismissed from the program.
- I understand that failure to follow the rules of conduct, participation and program standards may result in a loss of membership. Upon high school graduation and/or program departure, I give TS staff permission to access & receive any information related to post-secondary progression, including, but not limited to National Student Clearinghouse Student-Tracker Data, academic progress, and any financial aid received towards post-secondary completion.
Check the following*

AgreeDo not Agree
Code of Conduct

I will model appropriate behavior when participating in the TS Program. I further understand that I remain primarily responsible for my safety and conduct while participating in program activities. I also understand that my cooperation with
the TS staff, including participation in activities is essential to my continuation in the Program and overall academic and post-secondary success. Failure to obey behavior guidelines will result in loss of program membership.
Check the following*

AgreeDo not Agree
Field Trip Permission

Students will be taking field trips and will have the opportunity to explore many different aspects of Detroit, surrounding cities and post-secondary institutes, etc. Students will be supervised at all times by an TS staff. TS staff members will have cell phone and emergency contact information with them at all times.

I give permission for my child to go on field trips. I release CMU TRIO TS and individuals from liability in case of accident during activities related to activity, as long as normal safety procedures have been taken. I have read the above statement and understand. I consent for my student to take field trips during participation in the CMU TRIO TS.
Check the following*

AgreeDo not Agree
Media Release

I give my consent to CMU TRIO TS to use my name, photograph, portrait, and any likeness to any media form and type of publication. CMU TS will provide minimum identifying information and will not use street or mailing addresses, e-mail addresses, or phone numbers.
Check the following*

AgreeDo not Agree
Student's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Medical Information Form
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
mm-dd-yyyy
Hospital/Clinic Preference*
Physician's Name*

First NameLast Name
Phone Number*
(999)999-9999
Insurance Company Name*
Policy Number*
1. List allergies to food, medications, other. If none, so state.*
2. List pertinent medical information to heart trouble, diabetes, epilepsy, allergies, etc. If so, so state.*
3. Does student carry medication? (If none, state so.)*

Student Medication

	Medication Name	Amount & Time Taken	Purpose
1
2
3

4. Date of last Tetanus injection*

MonthDayYear
mm-dd-yyyy
5. Does student wear*

glassescontact lenseshearing aidnone
6. Does your child have asthma?*

YesNo
If so, do they have an inhaler?*
7. Additional medical information or comments
I hereby certify that the above information about my student is correct to the best of my knowledge and I understand this information is required for my student to participate in fieldtrips with the CMU TRIO TS Program. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. I also authorize CMU TRIO TS Staff to administer medication listed above at the indicated dosage and time as needed during field trips.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Authorization to Release and Obtain Information
The following information exchange is being requested from Detroit Public Community School District, Leona Group LLC Charter - Cesar Chavez Academy in order to facilitate coordinated program services. All information obtained by the agency and/or generated during the course of service is kept confidential and is not open to public inspection
Student Name*

First NameLast Name
D.O.B.*

MonthDayYear
mm-dd-yyyy
Parent Name*

First NameLast Name
Mail To:

CMU-TRIO Talent Search
900 Tower Drive, Suite 100
Troy, MI 48098
TYPE OF MATERIAL: Only checked information may be released*

All School Records on FileOfficial Student transcriptNon-Official Student transcriptSchool ScheduleReport CardAttendance RecordsCollege Transcripts/Grades/Schedules
I hereby authorize CMU Talent Search to obtain confidential academic information concerning the above named student(s) and the school to release this information. I also authorize Educational Talent Search staff to visit my child at school for the purpose of gaining information (educational/program).

I understand that my consent for the release of records is voluntary and I can withdraw my consent at any time in writing. Should I withdraw my consent, it does not apply to information that has already been provided under the prior consent for release.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
I DO NOT consent (please only sign if NOT consenting)
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Income Information
Family Household Size*
(total number of people living in the household or supported by parent/guardian)

Please indicate the Annual Benefit Amount below AND attach copy of documentation. If not receiving indicate 0.*

	Dollar Amount
Social Security
Disability
Foster child
Veteran's Benefits
Food Assistant Program
Family Independ. Program
Unemployment Benefits
Other (please explain below)

If Other, please explain*
Copy of documentation

Browse Files

Cancelof
ONLY Complete Federal income Chart verification if you MEET the income guidelines for TRIO Programs

Federal TRIO Programs 2023 Annual Low Income Levels are established by the US Census Bureau based on taxable income within 150% of the poverty level. The information below is taken from the U.S. Department of Education’s Federal TRIO Programs Annual Low Income Levels. Effective 1/19/2023 until further notice.

*Box checked below MUST match the number of family members in the household*

	Check ONE
No. in Family: 1; Federal TRIO Programs 2020 Annual Low Income Levels: $19,140
2; $25,860
3; $32,580
4; $39,300
5; $46,020
6; $52,740
7; $59,460
8; $66,180
Over 8; For family units with more than 8 members, add $6,720 for each additional family member for the 48 contiguous states.

Federal Income Guidelines (NO. in Family - Federal TRIO Programs 2023 Annual Low Income Levels)*

1 - $21,8702 - $29,5803 - $37,2904 - $45,0005 - $52,7106 - $60,4207 - $68,1308 - $75,840Over 8; For family units with more than 8 members, add $7,710 for each additional family member for the 48 contiguous states.
ONLY Complete income verification below, if you DO NOT meet the income guidelines for TRIO Programs

If you filed a 1040 (1040, 1040EZ, 1040 A) income tax form*

	Amount
Enter ADJUSTED GROSS income
Enter TAXABLE income

If you DID NOT file an income tax return, what is your gross income listed on your last payroll check for December? *
Please type n/a if you did complete an income tax return
Verification and Pledge

I verify that my total annual household income is accurate as recorded above. I understand that falsification of this information constitutes a federal violation and may cause immediate ineligibility and/or termination of membership in the Talent Search Program. If my child is accepted, I agree to support his/her participation in both the Academic Year and summer phases. I will model appropriate behavior when in the presence of students. I further understand that I remain primarily responsible for his/her safety and conduct while he/she is participating in program activities. I also understand that my cooperation with the TS staff, including participation in TS Parental activities is essential to my son/daughter’s admission and continuation in the Program.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy