Morehead State University-RPED-Non Trio-UB-Application Form

Rising Eagles Program Application-R.I.S.E-Rural Internship STEM Experiences
Attention Parents/Guardians & Students: Please complete this application together.

Thank you for your interest in the R.I.S.E. Program for Rising Eagles through the office of Rural Postsecondary & Economic Development at Morehead State University. Please complete the application below to express your interest in joining the program.

The R.I.S.E. Program emphasizes skills needed for securing job placement in high demand, high wage fields and offers career counseling services and internship placements for students.

The program is available to incoming and current Morehead State University students, as well as, 11th & 12th grade students in rural high schools in the following areas: Bath, Boyd, East Carter, Elliott, Fleming, Johnson Central, Lewis, Magoffin, Mason, Menifee, Montgomery, Morgan, Powell, Rowan, West Carter, Wolfe
For Income Eligibility: Most recent tax return (1040, 1040EZ, or 1040A) or tax transcript from the IRS.

For 1st Generation Eligibility: The definition of first generation, used to determine eligibility for the federal TRIO programs and Pell Grant, is a student whose parent or parents did not earn a bachelor's degree, according to an amendment to the Higher Education Act of 1965

The Release of Records is required for program participations. Records will be used to assess student needs, monitor progress, document eligibility, and for reporting purposes. This information is confidential and protected under the General Education Provision Act. Rural Postsecondary & Economic Development will not release any confidential information without your written consent.

R.I.S.E.-Release of Records
I hereby grant permission for the Rural Postsecondary & Economic Development program at Morehead State University to have access to educational records of my child ___________________________________________ including, but not limited to the following:

· Grades

· test scores

· free/reduced price lunch eligibility

· class schedules

· postsecondary enrollment

· discipline records

· attendance for the duration of the student's enrollment in the Rural Postsecondary & Economic Development program

This also authorizes the postsecondary institutions to release to the MSU Rural Postsecondary & Economic Development program copies of college academic enrollment and student aid award information.
Student Name (Print)*

First NameLast Name
Email*
example@example.com
Student Birthdate

MonthDayYear
Date
Parent/Guardian (if under 18yrs of age) or Student (if 18 years of age+) Name

First NameLast Name
Parent/Guardian Signature (if under 18yrs of age) or Student Signature (if 18 years or age +)

Clear
Date

MonthDayYear
Date

R.I.S.E-Rising Eagles Program -Photo & Video Release Form
Dear Parent/Guardian and Students,

Photos and videos are a great way to remember significant moments in life and celebrate student accomplishments. With your permission, the staff of the RPED program would love to take photos and videos of students for these purposes. Pictures and videos may be used for various print or media outlets including program promotions, newsletters, news articles, and official social media of the R.I.S.E Program or Morehead State University.

· By signing below, you grant Rural Postsecondary & Economic Development the right and unrestricted permission to use the students name, image, and voice in any photos, video recording, audiotapes, digital images, and the like, take or made on behalf of Rural Postsecondary & Economic Development R.I.S.E Rising Eagles Program or its partners.

· By signing below, you agree that Rural Postsecondary & Economic Development R.I.S.E. Rising Eagle Program has complete ownership of such material and can use said material for any purpose consistent with the Rural Postsecondary & Economic Development missions. These uses include, but are not limited to, photographs, videos, publications, advertisements, new releases, websites, social media, and any promotional or educational materials in any medium.

· By signing below, you acknowledge that you or whom you are signing on behalf of will not receive any compensation for the use of such images, videos, likeness, etc.
High School:
Grade Level

JuniorSeniorMSU College Undergraduate
Student Name (Print):
Parent/Guardian Name (if under 18yrs of age) or Student Name (if 18 years of age+)
Parent/Guardian Signature (if under 18yrs of age) or Student Signature (if 18 years of age+)

Clear
Date

MonthDayYear
Date

Contact Information
Name:

First NameLast Name
Student Date of Birth:

MonthDayYear
Date
Gender:

MaleFemalePrefer not to Answer
Social security number:
999-99-9999
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/guardian phone number:
(999)999-9999
Parent/guardian email:
example@example.com
Student phone number:
(999)999-9999
Student email:
example@example.com
Emergency contact name:

First NameLast Name
Emergency contact number:
(999)999-9999
Student shirt size:

Rising Eagles Program Application-R.I.S.E-Rural Internship STEM Experiences