Bluegrass Community & Technical-Lexington-TS-Application Form

TRIO EDUCATIONAL TALENT SEARCH PARTICIPANT APPLICATION
STUDENT INFORMATION
Student Name*

First NameMiddle InitialLast Name
Preferred Name
Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Emails:
School Email*
example@example.com
Personal Email
example@example.com
Student Phone Number
(999)999-9999
Date of Birth *

MonthDayYear
mm-dd-yyyy
Social Security #
999-99-9999
Cell Phone
(999)999-9999
Gender:*

MaleFemalePrefer not to sayOther
Citizenship Status:*

Yes, Student is a U.S. CitizenNoStudent is a Legal Permanent Resident and/or has an Alien Registration Number
Studentis a Legal Permanent Resident and/or has an Alien Registration Number
Race/Ethnic Background (check all that apply):*

Hispanic/LatinoBlack or African AmericanWhiteAsianHawaiian Native or Other Pacific IslanderAmerican Indian or Alaska NativeTwo or more (check all that apply)
What school are you currently attending?

Middle SchoolHigh School
___________ Middle School
___________ Middle School
____________ High School
____________ High School
Current Grade Level
Current Grade Level*
Anticipated High School Graduation Year
Briefly tell us why you want to participate in the TRIO Talent Search program. (1-2 sentences is preferred.)
If accepted into the BCTC TRIO Educational Talent Search Program, I agree to meet with my TRIO TS Academic Advisor(s), attend workshops/meetings, do my best academically, and prepare to enter postsecondary education after high school.
STUDENT SIGNATURE*

Clear
Date*

MonthDayYear
mm-dd-yyyy
CONTACT US

TRIO Educational Talent Search Program | Bluegrass Community & Technical College 117-N, Leestown Campus | Lexington, KY 40511 | https://bluegrass.kctcs.edu/community/talent-search/index.aspx Voice: 859.246.6574 | talent.search@kctcs.edu

Educational Talent Search, a federal TRIO program, is 100% funded by the U.S. Department of Education and sponsored by Bluegrass Community & Technical College, an equal opportunity institution.
Eligibility Information

PARENT/FAMILY INFORMATION (To be completed by parent(s) or legal guardian(s))
Please list name(s) of whom student lives with MOST of the time:

Both parentsSingle parentParent/StepparentOther (list below)
Parent 1

First NameLast Name
Parent 2

First NameLast Name
Stepparent 1

First NameLast Name
Stepparent 2

First NameLast Name
Legal Guardian

First NameLast Name
Foster Parent

First NameLast Name
Other

First NameLast Name
Does Parent 1 have a four-year college degree:

YesNo
Does Parent 2 have a four-year college degree:

YesNo
Cell Phone
(999)999-9999
Email
example@example.com
Eligibility Information:
PARENT/FAMILY INFORMATION (To be completed by parent(s) or legal guardian(s))
Who does the student live with most of the time:*

Both biological parentsSingle parentGrandparentsOther Legal GuardianFoster ParentsAdopted Parents
Guardian 1:
Name*

First NameLast Name
Relationship to student:*
Cell Number:*
(999)999-9999
Work Number:
(999)999-9999
Email:*
example@example.com
Does this person have a four year college degree:*

YesNo
Guardian 2:
Name

First NameLast Name
Relationship to student:
Cell Number:
(999)999-9999
Work Number:
(999)999-9999
Email:
example@example.com
Does this person have a four year college degree:

YesNo
FINANCIAL INFORMATION
The BCTC TRIO Educational Talent Search program is funded to serve a percentage of students who meet the eligibility criteria of low-income, first-generation potential college student status meaning neither parent has a four-year college degree. In meeting this federal regulation, we ask that you provide the following information used to determine eligibility. The information you provide is strictly confidential and used solely for the purpose of determining program eligibility.
Does anyone in the household receive:

Free or Reduced-Price School LunchEBT/SNAP/Food stampsWICTemporary Assistance for Needy Families (TANF)Supplemental Security Income
Total number of people in household (including yourself)*

12345678910+
Taxable Income (from the most recently completed tax form)*

(0) No Taxable Income(1) $1 - $23,475(2) $23,476 - $31,725(3) $31,726 - $39,975(4) $39,976 - $48,225(5) $48,226 - $56,475(6) $56,476 - $64,725(7) $64,726 - $72,975(8) $72,975 - $81,225(9) $81,226 and Higher

Please list dependents other than applicant and provide ages:

	Name	Age
1
2
3
4
5
6

Needs Assessment (My student needs assistance and/or should learn about the following, please check all that apply):

TutoringStudy SkillsLeadership SkillsCommunication SkillsTime Management SkillsACT/SAT PrepAcademic AdvisingCharacter DevelopmentGoal SettingPeer PressureCultural ExplorationCareer ExplorationCollege ExplorationBuilding RelationshipsOther
Authorization Form
RELEASE OF ACADEMIC/EDUCATIONAL INFORMATION

The parent/guardian authorizes the student’s school(s) to release any academic/educational information from the student’s files as requested by Bluegrass Community and Technical College Educational Talent Search and authorizes ETS to release academic/educational information to assist in the student’s education.

ACTIVITY, PHOTO, AND MEDICAL RELEASE

It is the policy of Bluegrass Community and Technical College ETS that informed written consent be granted for all photography and/or video recording. By signing below, the parent/guardian of the student applicant herby grants permission to ETS to photograph and/or videotape either the adult parent/guardian or minor child upon admission into ETS. The parent/ guardian also authorizes BCTC ETS to use and/or permit others to use the aforementioned images in educational, informational, and promotional activities for ETS without compensation.

PARENT/GUARDIAN PERMISSION

I, the undersigned, confirm that all the information on this application is true to the best of my knowledge and feel that my child has shown potential for success in a postsecondary education program. My child has my support in this endeavor as (s)he strives to be engaged in achieving success through participation in the BCTC TRIO Educational Talent Search program. I, too, commit to attending at least one Family Night Event per year.
PARENT/GUARDIAN SIGNATURE*

Clear
Date*

MonthDayYear
mm-dd-yyyy
STUDENT SIGNATURE*

Clear
Date*

MonthDayYear
mm-dd-yyyy

TRIO EDUCATIONAL TALENT SEARCH PARTICIPANT APPLICATION

STUDENT INFORMATION

Eligibility Information

FINANCIAL INFORMATION

Authorization Form