Southern Utah University-TS-2024 Application Form

TRIO ETS APPLICATION
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STUDENT INFORMATION
Name*

First NameMiddle InitialLast Name
Birthdate*

MonthDayYear
mm-dd-yyyy
Gender:*

FM
Current Grade:*

6789101112
School Attending*
Expected High School Graduation Year*
Student Mailing Address/PO Box*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Phone*
(999)999-9999
Student Email*
example@example.com
Are you a U.S. Citizen?*

YesNo
If no, are you a U.S. Permanent Resident?

YesNo
Alien Registration #
Are you Hispanic or Latino?*

YesNo
Race/Ethnicity:*

Asian/East IndianHispanicWhiteAmerican Indian or Alaska NativePacific IslanderBlack/African AmericanMore than 2 racesOther
Who do you live with?*

Both parentsMotherFatherGuardianOther
Languages spoken in the home:*
If English is not your first language, how comfortable are you reading, writing, and speaking in English?

Very comfortableComfortableSomewhat ComfortableNot comfortable
Are you currently enrolled in a TRIO Upward Bound Program?*

YesNo
Are you currently, or have you been in Foster Care in the past year?*

YesNo
Are you currently, or have you been Homeless in the past year?*

YesNo
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1
Parent Email*
example@example.com
Relationship to student:*

FatherMotherOther
Name: *

First NameLast Name
Phone:*
(999)999-9999
Place of Employment:*
Work phone:
(999)999-9999
Highest Level of Education Completed:*

Less than high schoolhigh school diplomasome collegeTrade CertificateAssociate's DegreeBachelors DegreeMasters DegreeProfessional or Doctorate Degree
Parent/Guardian 2
Parent Email*
example@example.com
Relationship to student:*

FatherMotherOther
Name: *

First NameLast Name
Phone:*
(999)999-9999
Place of Employment:*
Work phone:
(999)999-9999
Highest Level of Education Completed:*

Less than high schoolhigh school diplomasome collegeTrade CertificateAssociate's DegreeBachelors DegreeMasters DegreeProfessional or Doctorate Degree
Does either natural or adoptive parent have a Bachelor’s Degree (4 year college degree)*

YesNo
FINANCIAL ELIGIBILITY
What is your household size?*
For your student to qualify to be enrolled in TRIO ETS, they need to be eligible under the Federal TRIO Guidelines. Based on the guidelines below, does your student qualify? To start, view how many are in your household, next see where your taxable income level falls (look at your IRS from 1040). If your income is below that amount, or if you qualify for FREE lunch, your student qualifies for TRIO ETS.
Does your student qualify for FREE lunch?*

YesNo
Does your student qualify according to this chart?*

YesNo
STUDENT NEEDS ASSESSMENT
Check all that you would like to learn more about*

Study skillsHow to Pay for CollegeCommunication SkillsTest-taking skillsCollege Readiness SkillsSkills Needed for College & CareersTutoringAcademic AdvisementSTEM Opportunities & CareersACT PrepCareer InterestsFinding and Applying for ScholarshipsFinancial/Economic LiteracyFinancial Aid InformationCollege VisitsApplying for financial and, including FAFSATime ManagementCollege AdmissionsPersonal Organization
SIGNATURES AND RELEASE OF RECORDS/MEDIA
Our signatures below indicate that to the best of our knowledge, the information given on this application is true, complete and accurate. We authorize any public school, education program, and/or postsecondary institution to release to Southern Utah University TRIO Talent Search, upon their request, information pertaining to my academic, enrollment and financial assistance records.

With my signature below (parent, or student if 18 or over), I hereby grant permission to the staff of the Educational Talent Search Program at Southern Utah University to access my (my child’s) school records, including grades, test scores, attendance, and free or reduced lunch eligibility. These records will be used to assess student needs, monitor student progress, document eligibility for the
program, and for reporting purposes.

I (parent, or student if 18 or over) hereby authorize post-secondary institutions to release to TRIO Talent Search copies of college academic, enrollment and student aid award at the college/university I will be attending after high school graduation. As a parent or legal guardian signing this form, I give permission for my child to participate in all program sponsored activities. I also give permission for the use of my child’s photograph for editorial, promotional, recruitment, or educational purposes.
Parent/Guardian Signature*

Clear
Student Signature *

Clear
SUU TRIO ETS ACTIVITIES Participation Agreement for Minors
MINOR PARTICIPANT:
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN:
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DESCRIPTION OF ACTIVITY: (hereafter the Activity) TRIO ETS meetings, workshops, tours, use of campus
facilities, etc.

LOCATION: Multiple locations including the SUU campus and other schools.

DATES: Upon acceptance date to end of participant’s participation in TRIO ETS program.

This Activity Participation Agreement (the “Agreement”) is a consent, waiver, and release entered into between Southern Utah University (“SUU”), and the undersigned as Parent/Guardian of the Participant.

Guardian acknowledges that this Agreement contains, among other provisions, the following contractual terms: an assumption of risk, a covenant not to sue, a release of the Guardian and Minor’s claims, and indemnification obligations. Guardian represents that Participant is under 18 years of age and that Guardian is fully competent and authorized to sign this Agreement on Participant’s behalf. Guardian gives permission for Participant to engage in the Activity. In consideration for SUU permitting Participant to engage in the Activity, Guardian, for Participant, and for their respective heirs, personal representatives, and assigns, agrees as follows:

1. Assumption of Risk. Guardian represents that Participant is qualified, in good health, and in proper physical condition to participate in the Activity. Guardian acknowledges and understands that the Activity may include but is not limited to the following: physical activities (e.g., running, jumping, climbing); physical exertion such as lifting or moving heavy objects; spending extended periods of time outdoors being exposed to the elements (sun, wind, rain); travel to and from the Activity; and consumption of food and/or beverage Guardian acknowledges and understands that Participant may be exposed to certain risks that are inherent in participation in the Activity. These risks may include but are not limited to such things as incident related to the above-mentioned activities, including sprains, broken bones, cuts, bruises, entrapment, temporary or permanent disability, illness, personal injury, and/or death; adverse weather conditions; exposure to theft and other criminal activity; allergic reactions to food and drink items; other physical, mental, and emotional injury; other risks and dangers, whether known or unknown nor reasonably foreseeable. Guardian, on behalf of Participant, knowingly and voluntarily, accepts, and assumes responsibility for each of these risks and dangers, and all other risks and dangers that could arise out of, or occur during, Participant’s engagement in the Activity.

2. Covenant Not to Sue: Guardian for him/herself, and on behalf of Participant, agrees that Guardian will not commence any legal action or lawsuit or otherwise assert any legal claim against SUU and its officers, directors, employees, and agents seeking relief for any claim, whether or not such claim is released or waived under this Agreement.

3. Indemnification: Guardian agrees to indemnify and hold SUU and its trustees, officers, directors, employees, and agents harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, arising out of Participant’s involvement in the Activity and to reimburse SUU for any such expenses incurred.

4. Release of Claims: Guardian for him/herself, and on behalf of Participant, agrees to release and fully discharge the State of Utah, SUU, their agencies, departments, officers, employees, trustees, agents and all sponsors, officials and staff or volunteers from any and all liability, claims, demands, breach of warranty, negligence, malpractice, or any other actions, and causes of actions whatsoever for any loss, claim, damage, injury, illness, attorney’s fees or harm of any kind or nature to me or the Participant arising out of Participant’s participation in the Activity. This release extends to any claim made by parents or Guardian/s or their assigns.

5. Severability/Governing Law: Guardian agrees that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of Utah and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The Agreement shall be governed by the laws of the State of Utah, without regard to conflicts of laws principles. Venue for any lawsuits, claims, or other proceedings between the Parties relating to or arising under the Agreement shall be exclusively in the State of Utah.

6. Likeness Release: Guardian hereby grants absolute rights and permission to SUU staff and their sponsors to use photographic portraits and/or video footage of this minor for any and all illustration, promotion, or advertising.

7. Health Insurance and Consent to Medical Treatment: Should Participant require emergency medical treatment as a result of any accident or illness arising during the Activity, Guardian expressly consents to such treatment. Guardian acknowledges that SUU will not provide health and accident insurance for Participant, and Guardian agrees to be financially responsible for any medical bills incurred as a result of emergency medical treatment. Guardian agrees to release the State of Utah, SUU, and their agencies, departments, officers, employees, trustees, agents and all sponsors, officials and staff or volunteers from the cost of any medical care that Participant receives as a result of participation in the Activity.
Health Insurance Company/Policy #: *
Emergency Contact Name/Phone #:*
Acknowledgment: I am the parent or legal guardian of the Participant. I have carefully read and understand the contents of the foregoing language and I specifically intend it to cover Participant’s participation in the Activity.
Name:*

First NameLast Name
Signature of Parent or Guardian: *

Clear
Date*

MonthDayYear
mm-dd-yyyy

TRIO ETS APPLICATION

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

FINANCIAL ELIGIBILITY

STUDENT NEEDS ASSESSMENT

SIGNATURES AND RELEASE OF RECORDS/MEDIA

SUU TRIO ETS ACTIVITIES Participation Agreement for Minors