312890-Lake Land College-TS-2025 Application Form-Gavin

Do you want to go to college?
Our program assists students in middle school/junior high and high school in planning and preparing for their futures setting them up to achieve their goals. No Cost Federally Funded Program

WE CAN HELP YOU!

·       Fun activities

·       FREE trips to college & career sites

· Connections to Tutoring

·       Prepare for high school and college

·       Help completing college, scholarship, and other financial aid applications

·       SAT/ACT prep courses

·       Parent workshops

·       Leadership opportunities

CONTACT US TODAY!

217-234-5456

5001 Lake Land Blvd. Mattoon, IL 61938
- Please complete all information below. Incomplete applications will delay processing.
- Date of Application
  
  MonthDayYear
  Date
- Current Grade:
- School:
- Name
  
  First NameMiddle NameLast Name
- Preferred Name
- Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Student Cell
  (999)999-9999
- Please check this box if you do NOT want TRIO Destination College to text you.
- Student’s E-mail Address
  example@example.com
- Date of Birth:
  
  MonthDayYear
  Date
- Gender:
- Are you a citizen/Permanent Resident of the United States?
- Ethnic Background
- Student lives with:
  
  Other
- Parent/Guardian Information:
  
  First NameLast Name
- Relationship
- Parent Phone:
  (999)999-9999
- Please check this box if you do NOT want TRIO Destination College to text you.
- Do you have another child currenly participating in TRIO Destination College?
- If yes, please provide child’s name and school currently attending
- We would love to reach out to any siblings or a friends in middle school/junior high or high school NOT YET in the program, please list them.
- EDUCATION & INCOME VERIFICATION
  
  Lake Land College Destination College, a Talent Search project, is required by the US Department of Education to verify educational background and household income level for all participants. (34CFR643.10) All information will be held in strict confidence, and we will adhere to the Family Educational Rights and Privacy Act of 1974 (FERPA).
  
  Taxable Income is usually lower than the Total or Gross Income. Please call 217-234-5003 or 217-234-5048 if you have any questions or need assistance locating this information. If possible, please include a copy of your tax form with application. 34CFR643.7
- 1. Did either of the applicant’s parents, who live with the applicant, earn a baccalaureate degree (4-year degree) or Higher?
- 2. My household’s Annual Taxable Income (after deductions)for the previous year was:
- Or I have no taxable income and am not required to file a tax return.
- 3. Please provide the number in your household. Include yourself and anyone supported by your income.
- 4. Is the applicant in foster care and/or ward of the state of Illinois?
- RELEASE STATEMENT & AGREEMENT
  
  Please read carefully and sign where indicated. Failure to provide a signature will delay processing of the application.
  
  · I certify that the information provided is true and accurate to the best of my knowledge
  
  · I hereby authorize the release of all secondary & post-secondary school records to the Destination College program.
  
  · I authorize Destination College to share and discuss any information with my parents or legal guardians.
  
  · I understand that all information on this application as well as that released from the school will be held in strict confidence by Destination College.
  
  · I give permission to Destination College to take photographs during activities, trips, events and to use my child’s name and/or photo for Destination College educational and/or promotional purposes. *
  
  · Our signatures below indicate our commitment to our child’s education and Destination College.
  
  · I understand TRIO Destination College may contact me or my child by phone call, text, in person or virtually online.
  
  I understand that this authorization remains in effect while a participant in Destination College and through post-secondary education.
  
  I will provide Destination College with written notice to revoke the authorization.
- Student’s Printed Name
  
  First NameLast Name
- Student’s Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- Parent’s Printed Name
  
  First NameLast Name
- Parent’s Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- *Please check this box if you do NOT want TRIO Destination College to take photos of your child during activities and trips.
- STUDENT, PLEASE READ EACH STATEMENT AND SELECT THE ANSWER THAT BEST DESCRIBES YOUR NEED.
- I plan to continue my education after highschool by enrolling in a college, university, trade school or other training program.
- In high school, I plan to complete all classes needed to prepare for college.
- I participate in clubs, sports and/or volunteer. List in the box: Example: Football, Volleyball, Basketball, FFA, 4-H, Drama,Music/Band, Work, Other, Girl/Boy Scouts, etc…
- To improve my grades, I need tutoring in:
- I am in middle school/junior high or high school and am interested in help planning high school classes now or in the future.
- I need information about how to get ready for college and in completing college applications.
- I need help in preparing for testing, including SAT or ACT.
- I will need help in learning how to pay for college and in completing financial aid or scholarship applications.

Do you want to go to college?