Miami Dade College-North-TS-Application Form

Miami Dade College North Campus Talent Search

STUDENT APPLICATION FOR ADMISSION
The TRIO Educational Talent Search (ETS) Program at Miami Dade College – North Campus is a federally funded pre-college program that helps middle and high school students prepare for success in higher education. ETS offers free educational and enrichment services to support students’ academic and personal growth.

All information provided will remain confidential and used only to determine program eligibility.

Miami Dade College – North Campus
11380 NW 27th Avenue
Miami, FL 33167
Name of Middle/High School:*
Name of Middle/High School*

Miami Norland Senior High SchoolMiami Central Senior High SchoolNorth Miami Beach Senior High SchoolMiami Norland Middle SchoolOther
Student's Phone Number*
(999)999-9999
STUDENT PERSONAL DATA
the student is a veteran

YesNo
Name:*

First NameMiddle InitialLast Name
Email*
example@example.com
Personal Email*
example@example.com
school ID*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*
Grade*
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Sex:*

MaleFemale
Are you a U.S. citizen? *

YesNo
If no, are you a lawful permanent resident (Green Card holder)?*

YesNoN/A
Permanent US Resident Alien Registration Card #*
(Optional) Ethnicity/Race:

Hispanic/Latino of any raceBlack or African American, non-Hispanic/LatinoWhite, non-Hispanic/LatinoAmerican Indian or Alaska Native, non-Hispanic/LatinoAsian, non-Hispanic/LatinoNative Hawaiian or Other Pacific Islander, non-Hispanic/LatinoTwo or more races, non-Hispanic/LatinoOther
FAMILY INFORMATION
With whom does the Applicant live?*

MotherFatherFoster Parent(s)GrandparentOther
Father’s Name*

First NameLast Name
Cell Phone:*
(999)999-9999
E-mail:*
example@example.com
Has a 4-year degree:*

YesNo
Mother's Name*

First NameLast Name
Cell Phone:*
(999)999-9999
E-mail:*
example@example.com
Has a 4-year degree:*

YesNo
APPLICANT ASSESSMENT
1) What are your plans after high school?*

CollegeEmploymentMilitaryOther
2) Are you interested in receiving information about career options, educational opportunities and financial aid for college?*

YesNo
3) What are your career goals?*
4) Are there factors/inhibitors in your life that would prevent you from reaching your goals (some examples include low motivation, test anxiety, indecisiveness about your future, etc...)?*

YesNo
If yes, what are they? *
CERTIFICATION

I certify that all of the information provided on this application and in the Family Income Statement section of the application is true and complete to the best of my knowledge. I understand that Miami Dade College North Campus Talent Search may ask for proof of any information provided on this application, and I agree to provide the necessary documents. I understand that if I refuse to provide proof of any information given, the applicant may be denied acceptance into the Talent Search program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Name:*

First NameLast Name
FAMILY INCOME STATEMENT
Is the family receiving (Please check all that apply)?*

TANF/AFDCSocial Security/SSIMedicare/MedicaidVeterans BenefitsUnemploymentPublic HousingDisabilitySection 8 HousingChild SupportFood StampOther

Amount received: Please write NA if not applicable *

	Amount received
TANF/AFDC
Social Security/SSI
Medicare/Medicaid
Veterans Benefits
Unemployment
Public Housing
Disability
Section 8 Housing
Child Support
Other:

Which income tax form did you file this year?*

IRS Form 1040 (U.S. Individual Income Tax Return)IRS Form 1040-SR (U.S. Tax Return for Seniors)IRS Form 1040-NR (U.S. Nonresident Alien Income Tax Return)Did not file (no tax return submitted)
Please provide the following information from your most recent tax forms (1040 & 1040-A):*

SingleHead of HouseholdMarried Filing JointlyMarried Filing SeparatelyQualifying Widow(er)
Including yourself, how many people live in your household and are supported by your family’s income (related by birth, marriage, or adoption)? For parents/guardians: Household income refers to the total combined income of all family members who live together and share financial responsibilities (such as parents, guardians, and dependents). Do not include roommates or individuals who are not part of your immediate family or who do not share financial support.*
What is your taxable income?*
(Yearly, Bi-weekly or Weekly?)
Frequency of Pay*

WeeklyBi-WeeklyMonthlyAnnually
CERTIFICATION

I certify that all of the information provided on this application and in the Family Income Statement section of the application is true and complete to the best of my knowledge. I understand that Miami Dade College North Campus Talent Search may ask for proof of any information provided on this application, and I agree to provide the necessary documents. I understand that if I refuse to provide proof of any information given, the applicant may be denied acceptance into the Talent Search program.

I authorize the MDC Talent Search program to access and/or request copies of academic transcripts, grade reports, report cards, standardized test scores, contact information, and any other academic information from the high schools and colleges I attend through my college graduation. I understand that the U.S. Department of Education funds the MDC Talent Search program and will use these records to provide academic advisement and other services. I also understand that these records will be handled confidentially and that they will be made available only to program staff and representatives from the Federal and State Departments of Education. I/We also permit MDC Talent Search program to request the information identified above from each high school and college that our son or daughter attends. Note: A photocopy of this record release form should be accepted as an original and the date of the application has bearing when MDC Talent Search program requests the information.

I, being the parent or guardian hereby consent that the photograph/video of my son/daughter and/or to use their likeness in photograph(s)/video(s) in any of its publications, and in any media, whether now known or hereafter existing controlled by the MDC Talent Search program, in perpetuity and for other uses by the College or Program. I will make NO monetary or other claim against Miami Dade College Talent Search program for the use of the photograph(s)/video(s).
Parent’s Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Food & Snack Disclaimer
TRIO Educational Talent Search occasionally provides snacks or meals during program activities. Please indicate any food allergies or dietary restrictions below to help us ensure your safety and comfort.

No known allergiesAllergies/Dietary Restrictions
By signing below, I acknowledge that I have provided accurate information regarding food allergies and understand that TRIO ETS will make reasonable efforts to accommodate dietary needs.

Clear
If you have any questions or concerns please contact the Grant Director, Ms. Manouchka Clermont at 305-237-1828 or by email at mclermon@mdc.edu

Miami Dade College North Campus Talent Search

STUDENT PERSONAL DATA

FAMILY INFORMATION

APPLICANT ASSESSMENT

FAMILY INCOME STATEMENT

Food & Snack Disclaimer