Caldwell Community College & Technical Inst-TS-Student Application

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TRIO/ETS Application
MISSION
The mission of the CCC&TI TRIO Educational Talent Search (TRIO/ETS) Program is to provide equal access to quality education by facilitating retention and promotion from middle and secondary grades through college completion. We aim to:
- Provide opportunities for middle and high school students from underrepresented populations."
- Increase the number of those students to enroll in and complete their postsecondary education.
* Underrepresented populations include first-generation college students, students from low-income families, students of color, students with different learning or physical abilities, and more.

SERVICES
- College Tours
- College Admissions
- Test Prep (SAT/ACT)
- Financial Aid Assistance
- Computer Technology
- Personal Development
- Connections to Tutoring
- Goal Setting
- Positive Self-Imaging
- Summer Academic Enrichment
- Career Enrichment
- Cultural Trips (museums, theater, etc.)
- Academic Counseling
MIDDLE SCHOOLS
- Happy Valley
- Kings Creek
- William Lenoir
- Collettsville School
- Gamewell Middle
- Granite Falls Middle
- Hudson Middle
Homeschool Students Welcome

HIGH SCHOOLS
- Hibriten
- South Caldwell
- West Caldwell
CCC&TI Campus:
- Caldwell Applied Sciences Academy
- Caldwell Early College
Homeschool Students Welcome

HISTORY & LOCATION

Caldwell Community College & Technical Institute introduced its first TRIO program in 1993, TRIO Student Support Services, followed by TRIO Educational Talent Search (TRIO/ETS) ten years later. TRIO/ETS serves 500 students annually in Caldwell County middle and high schools. Since its inception, TRIO/ETS has served thousands of students providing access to higher education to first generation, or underrepresented students.

The main office for TRIO/ETS is located on the Hudson campus of Caldwell Community College & Technical Institute (2855 Hickory Blvd Hudson, NC 28638). Normal office hours are 8:00 am to 5:00 pm Monday through Friday. TRIO/ETS Success Coaches meet regularly with and provide services for students during the school day at their middle or high school. Various locations on the campus of CCC&TI are used to facilitate program activities and events during the weekday and on weekends.

APPLICATION
Caldwell Community College & Technical Institute
TRIO Talent Search Program
APPLICATION
Caldwell Campus: 2855 Hickory Blvd, Hudson, NC 28638
Phone: (828)726-2726 Email: trioets1@cccti.edu
Web site: http://www.cccti.edu/trio/
Caldwell County Student ID Number:
* This is the same as your lunch number.* If you are homeschooled or a student at Oak Hill School, please note 'homeschooled' or' Oak Hill' in this box.
Student Name*

First NameLast Name
What size t-shirt (adult unisex) does the student wear?*
Date of Birth*

MonthDayYear
mm-dd-yyyy
Age:*
Gender:

MaleFemaleOther, please explain
US Citizen: *Because TRIO is funded through the federal government, we are only able to serve U.S. citizens. This is strictly self-reported.*

YesNo
Grade Level*
Expected graduation year:
School Currently Attending:*

Happy ValleyKings CreekWilliam LenoirCollettsville SchoolGamewell MiddleGranite Falls MiddleHudson MiddleHibritenSouth CaldwellWest CaldwellCASACaldwell Early CollegeHomeschoolOak Hill Charter SchoolOther
Race (for Statistical Purposes Only)*

Native AmericanAsian/Pacific IslanderAfrican AmericanWhiteHispanicNative HawaiianMore than one raceOther
What is the primary language spoken at home?

EnglishSpanishOther, please explain
Student Cell Number*
(999)999-9999
Additional Cell /Home Phone
(999)999-9999
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email:*
example@example.com
School Email (if different from student email)
example@example.com
Parent/Guardian Email *
example@example.com
Number in household (including yourself):*

List below:*

	Name	Relationship to Applicant	Age
1. (self)
2.
3.
4.
5.

If there are more than 5 people in your household, please check below

If there are more than 5 people in your household, please check here
Needs Assessment: I am in need of the following services (check all that apply)*

College Admission InformationFinancial Aid InformationCareer InformationConnections to TutoringAdvice in Course selectionOther (Please specify)
Student Signature*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Goal Statement (briefly describe your goals and the importance of education to you)*
Are you a participant in the Communities in Schools (CIS) program?

YesNoI'm not sure
Were you a recipient of the Dream Award from Caldwell Community College & Technical Institute when you were in 6th grade?

YesNoI'm not sure

Emergency Contact and Medical Information
Emergency Contact Other Than Parent*

First NameLast Name
Cell Phone*
(999)999-9999
Home
(999)999-9999
Work
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Information
Physician’s Name*
Phone Number*
(999)999-9999
Insurance Company (list “NA” if there is no insurance policy)*
Phone Number
(999)999-9999
Allergies/Special Health Considerations (please list, "NA" if none)*
Please list any medications prescribed to your child that are currently being taken: (NA if none)*
I authorize CCC&TI's TRIO Educational Talent Search Program and hospitals to perform any and all necessary medical treatment 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.
Parent’s/Guardian’s Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Please provide any additional information concerning health issues/medication related to your child:

Information Release
INFORMATION RELEASE

The information requested below will be utilized to assist us in providing services to you. In order to provide the most effective services, we may need to obtain information from several sources; such as middle schools, high schools, colleges, testing agencies, counselors, admissions and financial aid officers, social workers, etc. ALL THE INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY RIGHTS AND PRIVACY ACT.

My signature below authorizes the TRIO/ETS program to:

Request a copy of my high school and/or college progress report, transcript, test scores, and/or documentation of behavior, grade promotion or graduation;

Request a copy of my middle school progress report, report card, and/or documentation of behavior, grade promotion, retention, matriculation, and transfer records;

Request a copy of my financial aid applications and awards from the federal government, state funding agencies, and postsecondary institutions;

Request a copy of my test score reports (ACT, SAT) from the American College Testing Program, College Board, and Educational Testing Service;

Communicate with representatives from agencies or postsecondary institutions on my behalf.

Authorization Statement

I hereby authorize TRIO Talent Search to contact and request information from, as well as supply information to, the above mentioned parties.
Student Signature*

Clear
Student School ID:
Parent's Signature*

Clear
Date:*

MonthDayYear
mm-dd-yyyy

Internet/Photo Release Agreement
My signature below indicates that I am providing consent for my son/daughter to utilize the Internet for educational purposes in accordance with the Acceptable Use Policy of CCC&TI. Additionally, I agree and consent to allow the photographs, and/or audio/video recordings taken or created during ETS activities to be placed on the Web and in public information materials. I hereby waive any right to inspect or approve the finished electronic, photograph, or printed matter that may be used in conjunction with them now or in the future. I further agree to allow the TS Program to release, for educational purposes, photographs and video recordings, with or without audio, of program activities and projects including my child and/or their likeness. I am expressly releasing CCC&TI, its agents, employees, licensees and assigns from any and all claims which I may have for invasion of my child’s privacy, right of publicity, defamation, copyright infringement, or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast or exhibition of such recordings.
I do not give permission for my child to be used in any public or promotional materials.

I do not give permission for my child to be used in any public or promotional materials.
Student Participant*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Participant*

First NameLast Name
Parent/Guard. Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
ETS Success Coaches will work with students to sustain and/or improve academic grades as needed. As a part of this effort, Success Coaches will periodically receive academic updates from teachers and administrators at the students' schools. By submitting this TRIO/ETS application, you are agreeing to give our Success Coaches access to this information.
If you were referred to TRIO by another student in TRIO, please list their name(s) here:

TRIO/ETS Application

Learning/Physical Differences