Pensacola State College-TS-2023 Application Form

Student Application
Thank you for your interest in the TRIO Educational Talent Search (ETS) program at Pensacola State College! Our goal is to help students successfully transition from middle to high school, graduate, and enroll in postsecondary education.

We proudly serve students in grades 6-12 in our target school districts, Escambia and Santa Rosa Counties, at the following schools:

Middle Schools: Avalon, Bailey, Bellview, Beulah, Brown Barge, Central, Ferry Pass, Hobbs, King, Ransom, Workman

High Schools: Central, Escambia, Milton, Pace, Pensacola, Pine Forest, Tate, Washington, West Florida

Please complete the application in one sitting—it cannot be saved and resumed later. We recommend gathering all required information before starting. If you have any questions, feel free to contact our office at (850) 484-1620 or email ets@pensacolastate.edu.
Student Information
Date

MonthDayYear
mm-dd-yyyy
Attach a copy of your student’s most recent Report Card*

Cancelof
Please check below any areas in which your student currently needs or would like to receive assistance/information:

Study Skills / Test taking StrategiesFinancial Aid ResourcesCareer Planning and AdvisingCollege Information / Specific College Program informationTutoring
Tutoring Subject(s):
Name*

First NameMiddle Int.Last Name
School:*
School*
Other:*
Grade:*
Grade*
Other:*
Student ID #*
Street Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Present Age:*
Student email:*
example@example.com
Student Cell*
(999)999-9999
Is your student a U.S. Citizen?*

YesNo
Student Social Security Number:*
999-99-9999
If no, U.S. Permanent Resident #:
Other (Specify):
Gender:*

MaleFemale
Ethnicity (mark the one which you most closely identify):*

American Indian/Native AlaskanAsianBlack/African AmericanCaucasian / WhiteHispanic/ LatinoNative Hawaiian or Other Pacific IslanderMultiracial
Is your student a high schooler who is currently Dual Enrolled?

YesNo
If yes, where?
Is your student involved in Take Stock in Children?

YesNo
Is your student eligible for the free or reduced lunch program at school?

YesNo
Who referred you/How did you hear about us?
Family Information
Check who the student lives with:*

Mother (natural or adoptive)StepmotherFather (natural or adoptive)StepfatherFoster CareGuardian (Specify):
Parent/Guardian #1 Name:*

First NameLast Name
Relationship to student:*
Cell Phone Number*
(999)999-9999
E-mail:*
example@example.com
Are you a veteran or active duty military?*

YesNo
Occupation:*
Highest level of education completed?*

N/AHigh School/GEDAssociate's degree (2 year)Bachelor's degree (4 year)Master's degree & higher
Would you like to provide information for a second parent or guardian?
Would you like to provide information for a second parent or guardian?

YesNo
Parent/Guardian #2 Name:*

First NameLast Name
Relationship to student:*
Cell Phone Number*
(999)999-9999
E-mail:*
example@example.com
Are you a veteran or active duty military?*
Occupation:*
Highest level of education completed?*
How many people live in your household? (Including yourself)*
Does the student have siblings in grades 6 – 12 currently attending school?

YesNo

Siblings:

	Name	School	Grade
1
2

Household Taxable Income

Please note that Taxable Income is usually LOWER than the Adjusted Gross Income. Taxable Income can be found on line 15 of the IRS 1040 tax form. If you have any questions, please call (850) 484-1620.
Check either Option 1 or 2, whichever best represents your household’s income.
Please Select:*

Option 1: Self-Reported household TAXABLE income of the household where the student spends 50% or more of their time. (List Taxable)Option 2: Other Nontaxable Income
Check your TAXABLE income: (only one)*

$0 - $23,475$23,475 - $31,725$31,725 - $39,975$39,975 - $48,225$48,225 - $56,475$56,475 - $64,725$64,725 - $72,975$72,975 - $81,225Higher than $81,225
The U.S. Department of Education requires the Educational Talent Search Program to obtain income information from all students served. Your child is not eligible for any services unless the information is provided.
Attach a Copy of your most recent IRS Form 1040*

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Check any if applicable:*

DisabilityAFDCVeteran BenefitsRetirementUnemploymentOther
Parent Name:*

First NameLast Name
I, {parentName}, the parent or guardian of the above-named student, certify that, to the best of my knowledge, this information is true and correct.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Information Consent
Consent to Communication by Text Message

By signing this form, I authorize the TRIO Educational Talent Search (ETS) Program at Pensacola State College (PSC) to send text messages to my cell phone to convey information regarding upcoming events, services provided, and important information related to student academics. I understand that standard text messaging rates will apply to any messages received from TRIO ETS. I agree not to hold TRIO ETS or PSC liable for any electronic messaging charges or fees generated by this service. I further agree that in the event my cell phone number changes I will inform the TRIO ETS Program.
Parent/Guardian Signature*

Clear
Printed Name:*

First NameLast Name
Post-Secondary Reporting

I, {printedName}, the parent or guardian of the above-named student, do hereby give permission for the release of transcripts, test scores, placement in any secondary or post -secondary institution, and type and amount of financial aid received, or other pertinent information required by the Pensacola State College TRIO-Educational Talent Search (ETS) program. I understand that only authorized ETS personnel will have access to such information for participation in the ETS Program and receipt of ETS services.
Parent/Guardian Signature*

Clear
Notification of Social Security Number Collection and Usage

In compliance with FL Statute 119.071(5), Pensacola State College (PSC) issues this notification regarding the purpose of the collection and use of a Social Security Number (SSN) in relation to the student’s participation in the Educational Talent Search (ETS) Program.

PSC collects Social Security Numbers for use in performance of the College’s and ETS Program duties and responsibilities. To protect the student’s identity, PSC will secure the Social Security Number from unauthorized access. PSC will never release a Social Security Number to unauthorized parties. As an ETS participant, the SSN is used for all associated educational purposes and federal USDOE reporting requirements.

The public-school system in Florida uses the Social Security Number as a student identifier (section 1008.386, F.S.). In a seamless K-12 system, it is beneficial for postsecondary institutions to have access to the same information for purposes of tracking and assisting students in the smooth transition from one education level to the next. All Social Security Numbers are protected by federal regulations and are never released to unauthorized parties.

Financial Aid

A student’s Social Security Number is required for the following financial aid purposes:

The United States Department of Education’s (USDOE) Free Application for Federal Student Aid (FAFSA) requires all applicants to report their SSN to be used for all federal financial aid programs as a student identifier for processing and reporting. In addition to its use by USDOE as a student identifier, the SSN is required in order for the Department of Homeland Security to investigate citizenship status, for the Federal Work Study Program, and is required on all loan applications for use by the lender/servicer/guarantor. PSC collects a student’s SSN on certain institutional scholarship applications for student files and federal and state audit/reporting purposes. If you are a recipient of a State of Florida grant or scholarship such as the Florida Student Assistance Grant, Florida Work Experience or Bright Futures the State of Florida Department of Education will require the use of the SSN on their grant/scholarship disbursement website and for reporting purposes.
Student Signature*

Clear
Parent/Guardian Signature*

Clear
Student SSN:*
999-99-9999
Photography Release

This Photography Release Form confirms the agreement between you and The District Board of Trustees of Pensacola State College, Florida (the “College”) regarding your participation in the College’s Educational Talent Search Program (ETS) in which you may be photographed or videotaped (the “Property”).

For valuable consideration received, you hereby irrevocably grant to the College perpetually, exclusively, and for all media throughout the world (including print, non-theatrical, home video, CD-ROM, internet and any other electronic medium presently in existence or invented in the future), the right to use and incorporate (alone or together with other materials), in whole or in part, for advertising, publicity, or any other purpose, photographs or video footage taken of you as a result of your participation in the College’s Educational Talent Search Program.

You hereby agree that you will not bring or consent to others bringing any claim or action against the College on the grounds that anything contained in the Property, or in the advertising and publicity used in connection herewith, is defamatory, reflects adversely on you, violates any other right whatsoever, including, without limitation, rights of privacy and publicity. You hereby release the College, its trustees, officers, employees, agents, successors and assigns from and against any and all claims, demands, actions, causes of action, suits, costs, expenses, liabilities, and damages whatsoever that you may hereafter have against the College in connection with the Property.

This agreement shall not obligate the College to use the Property or to use any of the rights granted hereunder, or to prepare, produce, exhibit, distribute or exploit the Property.

The College shall have the right to assign its rights hereunder, without your consent, in whole or in part, to any person, firm or corporation.
AGREED TO AND ACCEPTED this

MonthDayYear
mm-dd-yyyy
OR

Check this box if your student can not be in any ETS photographs.
Student Signature:*

Clear
Printed Name:*

First NameLast Name
Parent Signature:*

Clear
Printed Name:

First NameLast Name
This section is for Escambia County Students only.
Please have a friend, family member, or coworker witness this form.

Note: This Records Release Form does NOT have to be officially notarized.
Records Release

ESCAMBIA COUNTY, FLORIDA SCHOOL DISTRICT
Name of Parent or Guardian:

First NameLast Name
Name of Student:

First NameLast Name
Student Date of Birth:

MonthDayYear
mm-dd-yyyy
I, {nameOf}, hereby certify that I am the parent or legal guardian of {nameOf78}, DOB:{studentDate}.

I hereby autorize the release of information and/or records concerning said student in the custody and/or control of the Escambia County School District or its employees to:

TRIO Educational Talent Search at PSC

1000 College Blvd, Pensacola, FL 32504
Name and Address where records are to be sent:
I hereby waive any privacy claims under FERPA, HIPAA, or other applicable law for such release of records. This release is valid and shall continue in force until revoked by me in writing, furnished to the office of the School Board General Counsel, 75 North Pace Boulevard, Pensacola, FL 32505.
Signature*

Clear
Print Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
mm-dd-yyyy
Witnessed by:

Clear
Print Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
mm-dd-yyyy
(Note: cannot be witnessed by the person receiving the records; must be a third party)

Student Application

Student Information

Family Information

Household Taxable Income

Information Consent

This section is for Escambia County Students only.