Southwestern Oregon Community College-Satellite-TS-Application Form

Southwestern Oregon Community College Talent Search (TS) Application
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Student Information
Legal Name:*

First NameMILast Name
Preferred Name:
Current School Attending:*
Graduation Year:
Grade:*

6789101112
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Gender:

FemaleMale
Preferred Pronouns:
DOB:*

MonthDayYear
mm-dd-yyyy
Age:
T-Shirt Size
Students email:*
example@example.com
Social Security Number:
999-99-9999
Students Cell #:
(999)999-9999
Home #:
(999)999-9999
How did you learn about the TS program? (Print name of person/program):
Citizenship:*

Citizen or national of the United StatesPermanent Resident of the United StatesIn the United States for other than a temporary purpose and provides evidence from the Immigration and Naturalization Service of his or her intent to become a permanent residentPermanent resident of Guam, the Northern Mariana Island or the Trust Territory of the Pacific Islands (Palau) orIs a resident of the Freely Associated States - the Federated States of Micronesia or the Republic of Marshall Islands
Please provide a copy of your alien registration of I-94 form:

Cancelof
If born outside the U.S., please specify which country:
Race/Ethnicity:
A. Are you Hispanic/Latino:*

YesNo
B. Select all that apply:*

American Indian or Alaskan Native, non-Hispanic/LatinoAsian, non-Hispanic/LatinoBlack or African-American, non-Hispanic/LatinoWhite, non-Hispanic/LatinoNative Hawaiian or other Pacific Islander, non-Hispanic/LatinoTwo or more races, non-Hispanic/LatinoRace or Ethnicity Unknown
Are you a foster youth?*

YesNo
Are you a ward of the court?*

YesNo
Please provide documentation:

Cancelof
If you said yes, please include your case worker contact information
Parent Information
Student Resides with:*

Both parentsMother OnlyFather OnlyParent & StepparentFoster Parent(s)Legal Guardian(s)Other (specify)
Parent/guardian 1
Name:*

First NameLast Name
Relationship:*
Occupation/Job Title:*
Contact Phone #:*
(999)999-9999
Email:*
example@example.com
Have you received a four-year degree from a college or university?*

YesNo
Check here if TS can send you text/email notifications:

Check here if TS can send you text/email notifications
Parent/guardian 2
Name:

First NameLast Name
Relationship:
Occupation/Job Title:
Contact Phone #:
(999)999-9999
Email:
example@example.com
Have you received a four-year degree from a college or university?

YesNo
Check here if TS can send you text/email notifications:

Check here if TS can send you text/email notifications
Parent(s) preferred language:
What primary language is spoken a home?
Need for Service
I would like assistance in (please check all that apply):*

Career InformationCollege ExplorationAcademic ImprovementTest Taking SkillsStudy SkillsTime ManagementSummer Program InfoScholarship & Financial Aid Info
Parent/Guardian Income Information

APPLICATIONS WILL NOT BE PROCESSED, IF SECTION BELOW IS NOT COMPLETED. If applicant is a foster child, please provide proof of foster care status and skip to the signature section. Otherwise answer questions below.
What is the TOTAL number of persons in your household?*
Please provide your family's total TAXABLE income (IMPORTANT - use the amount from 2022-IRS form 1040 line 15)*

$0-21,870$21,870-29,580$29,580-37,290$37,290-45,000$45,000-52,710$52,710-60,420$60,420-68,130$68,130-75,840More Than $75,840
Please provide your family's total TAXABLE income (IMPORTANT - use the amount from 2023-IRS form 1040 line 15)
(Note: Your TAXABLE income can be found on the federal income tax return you filed for the last calendar year. All IRS forms will have a separate line for the total TAXABLE income: do not confuse it with your total wages or your adjusted gross income.)
Special Circumstances:

I DID NOT file a Federal Income Tax Return for the last calendar year.I had no taxable income for the last calendar year (if you checked this option an additional form may be required)
My family's income was:
Parent/Guardian Signature:

Clear
Parent/Guardian Authorization
Medical Release: Should my student require medical attention while participating in TS activities and I cannot be contacted. I give my consent to medical examination and treatment deemed necessary by the attending medical professional.

Mandated Reporting: Most information shared between participants and Program Representatives is held completely confidential. Please be aware of the few exceptions. Information shared regarding abuse (physical, mental or sexual) and/or harm to oneself or others must be reported by law to the appropriate individuals.

FERPA Consent: I hereby give TRIO/TS Program staff permission to have access to grades, progress reports, school transcripts assessment test scores, school lunch program eligibility and updated contact information from school administration. I authorize TS to obtain information related to my child’s application for college admission and acceptance status, financial aid application (FAFSA) and award letter at any and all colleges and universities. I authorized the release of verifying placement and retention in college and/or employment after graduating high school to provide support with retention in college and employment.

Media Release: I hereby give permission to the TRIO/TS Program Staff to photograph my child for promotional purposes and/or file records related to the TRIO/TS Program and/or statements to the used by TS for promotion, publicity or instructional purposes.

Participation: I, as the parent and student agree to participate in TS activities. I, the student, agree to do well in high school and pursue post-secondary education and I, the parent, will support and encourage my child in these efforts.

In consideration of granting permission by the Talent Search (TS) program for the above-named minor to participate in the activities sponsored by Southwestern Oregon Community College (SWOCC) TS. The participant, his/her parents(s) or legally appointed guardian hereby agree to indemnify, hold harmless, release and forever discharge the employees and/or agents from all claims and demands which the participant, his/her parent(s) or legal guardian or the representatives or successors of them or any person may have against SWOCC, its employees and agents by reason of acts, illness, injury or other consequences arising or resulting directly or indirectly from the participation of said minor in the aforementioned.

Note: All personal records or documentation will be held in strictest confidence by the staff of TS and SWOCC. (Consistent with the Federal Family Education Rights and Privacy Act of 1974, regulations and other laws). Personal records will not be released to any other entity without my prior acknowledgment and consent. This acknowledgement will be effective for the duration of my child’s participation in the program

By signing my name on the signature line, I certify that each response within the application is true and complete to the best of my knowledge. It also indicates that I acknowledge and give consent to the request of the TS Program.
Student Name (Please print name):*

First NameLast Name
Student Signature:*

Clear
Date:

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name (Please print name):*

First NameLast Name
Parent/Guardian Signature:*

Clear
Date:

MonthDayYear
mm-dd-yyyy
Do you receive any of these benefits?

SNAPTANFSection 8 Housing
Questions?

Contact us at (541) 888-7223

You can also visit our office or apply online: Southwestern Oregon Community College

1988 Newmark Ave, Coos Bay, OR. 97420

Room 8 Randolph Hall

Southwestern Oregon Community College Talent Search (TS) Application

Student Information

Parent Information

Need for Service

Parent/Guardian Income Information

Parent/Guardian Authorization