Cleveland Community College-TS-Application Form

Application for TRIO Talent Search
TRIO Talent Search is a federally funded program in cooperation with your student’s school. We provide career exploration, academic advising, financial counseling, college tours, cultural activities, mentoring, etc. to assist students with the potential to succeed in higher education. Our goal is to support CCS 6th-12th graders who will be first-generation college students from families with limited income. Our services are FREE to TRIO students.
STUDENT INFORMATION

All information will be kept confidential and used only for eligibility and consent purposes.
Student Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
Age*
School Email Address*
@clevelandcountyschools.org
Student Cell Phone:*
(999)999-9999
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Phone:*
(999)999-9999
Student ID/Lunch Number*
School*

BMSBHSCECHSCMSCHSKMMSKMHSSMSSHS
Grade*

6789101112
Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic/Latino of any raceNative Hawaiian or Pacific IslanderNo responseRace/ethnicity unknownTwo or more racesWhite
Gender*

MaleFemaleNo Response
Are you a US Citizen?*

YesNo
Student Authorization
Commitment and Permission: I would like to participate and receive the FREE services of the TRIO Talent Search Program. I understand I must maintain at least a 2.0 GPA (“C” average) on a 4.0 GPA scale and have good attendance at school. I agree to comply with behavior policies of my school and community. I will meet with my TRIO Talent Search Success Coach either individually or as part of a group activity at least twice a semester. I understand that failure to comply with these regulations may result in dismissal from the program. TRIO Talent Search program is granted my permission to verify financial aid information, postsecondary enrollment, retention, and completion information.

Media Release: I give permission to the TRIO Talent Search program to use my name, photograph, and audio/video recordings for editorial, promotional, recruitment and/or educational purposes. I certify that all the above information is true and accurate.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
FAMILY INFORMATION
Parent/Guardian Name:*

First NameLast Name
Relation to Student*

MotherFatherLegal GuardianFoster ParentGrandparentAunt/UncleOther
Is your mailing address the same as student?*

YesNo
Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the primary language spoken at home?*

EnglishSpanishOther
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Cell Phone Number*
(999)999-9999
Is there any medical information about your student (allergies, medial conditions, medications, etc.) you feel would be helpful for us to know?*
What parts of TRIO would benefit your student? (Check ALL that apply)*

College tours and help applying to collegeAccess to tutoring, test prep, and/or mentoringCultural activitiesFinancial literacy informationAcademic advising (help selecting classes)Information on financial aid for college
Has the birth mother or father (or legally adopted mother or father) of the student earned a 4-year degree from college? (Check one)*

Yes, the student has a parent/adopted parent with a 4-year degree.No, the student does NOT have a parent/adopted parent with a 4-year degree.
REQUIRED Federal Eligibility Information

Please answer the questions below.
If your current annual income falls within the range that matches your Members of Household, your student is eligible for TRIO. (Check one)*

Yes, my student meets this eligibility requirement based on the income levels provided.No, my student does not meet this eligibility requirement based on the income levels provided.
Number of members in household: *
Income level based on taxable income:*

$0 - $23,940$23,941 - $32,460$32,461 - $40,980$40,981 - $49,500$49,501 - $58,020$58,021 - $66,540$66,541 - $75,060$75,061 - $83,580$83,580+
Parent/Legal Guardian Authorization
School Records: I hereby authorize the TRIO Talent Search program to have access to my child’s permanent school records and other information necessary to determine program eligibility and assist in achieving educational goals. TRIO Talent Search program is granted permission to verify financial aid information, postsecondary enrollment, retention, and completion information.

Media Release: I give permission for the use of my child’s name, photograph, and audio/video recordings for editorial, promotional, recruitment and/or educational purposes.

I certify that the above information is true and accurate to the best of my knowledge.
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Please visit our website for more information at www.ClevelandCC.edu/trio-talent-search. Questions? Call Sarah Thomas, Director at 704-669-4189 and leave a message or email us at talentsearch@clevelandcc.edu.

Application for TRIO Talent Search

STUDENT INFORMATION

Student Authorization

FAMILY INFORMATION

REQUIRED Federal Eligibility Information

Parent/Legal Guardian Authorization