Daytona State College-TS-Application Form

As required by the US Department of Education, please complete the following questions to be considered for the DSC TRiO Talent Search Program

Note: You must be a US citizen or legal resident of the United States in order to participate in and receive services from DSC TRiO Talent Search Program

All information is required to be considered for the program.

To parent or legal guardian: The personal information, including financial status and educational levels provided below, is used for reporting purposes with the Department of Education. The information is required to determine eligibility established by regulation of the Department of Education and will remain confidential and is protected under the Family Educational Rights and Privacy Act (FERPA, 20 USC 1231a).

Please note that Taxable Income is usually lower than the Adjusted Gross Income. Taxable Income can be found on line 15 of your most recent tax return. If you have any questions, please call (386) 246-4857.
Please attach last year’s tax form, OR self-report household income information below.

If you DID NOT file a tax form, complete the following:

Please read the following statement, then sign and date.
My signature below verifies that the information that I have provided to the DSC TRiO Talent Search program is true and correct. (This information is protected by the Privacy Act. No one may see the information unless they work with or for the DSC TRiO Talent Search Program or are specifically authorized to see it.)

For my child to remain eligible to participate in the DSC TRiO Talent Search program, I will:
■ Ensure my child meets with a DSC TRiO Talent Search Coordinator at least
once per month
■ Notify DSC TRiO Talent Search staff if my child receives disciplinary action at school
■ Attend parental workshops provided by DSC TRiO Talent Search
■ Notify the DSC TRiO Talent Search office about any changes in contact information
■ Encourage my child to seek academic assistance when needed (ask about tutoring options)
■ Encourage my child to participate in DSC TRiO Talent Search program workshops,
activities,and campus visits
I certify that the information provided is true and accurate to the best of my knowledge. I understand that my child is required to meet with a Talent Search Coordinator at least once per month and participate in Talent Search activities whenever possible. I understand that my involvement and support is critical to my child’s success and I fully support my child’s participation in the DSC TRiO Talent Search program.

Permission to Access Student Academic Records
I give permission for DSC TRiO Talent Search to retrieve, store and report education verification information and student outcomes research that is gained from the National Clearinghouse and other services. By signing this document, I give permission to Flagler County Schools to release my child’s academic records to DSC TRiO Talent Search staff.

LIABILITY RELEASE
As the legal parent/guardian of the student named in this application, I hereby join in the release of Daytona State College, its trustees, officers, employees and agents from any and all liability or claims for losses or damages that the student may sustain while participating in travel activities sponsored by the DSC TRiO Talent Search program. The undersigned expressly understands and agrees that Daytona State College, its trustees, officers, employees, and agents assume no liability for the student’s participation in travel  activities.

RELEASE/CONSENT TO USE PHOTOGRAPHS
Photographs of our participants may be included in our website or other college-approved media. We require your authorization to use any photos we take of your child.

Please read and sign if you agree to the following terms:
I hereby irrevocably consent to and authorize the use and reproduction by Daytona State College, or any person or organization authorized by Daytona State College of any photographs or videos which have been taken of my child, both singularly and as a part of a group, without any compensation to me. All positives and negatives shall constitute solely the property of Daytona State College.

STUDENT PARTICIPATION AGREEMENT
I, (PRINT STUDENT NAME), hereby agree to attend all required meetings and workshops. I will commit myself to the DSC TRiO Talent Search program until I graduate from high school. I am aware that I must meet with my TRiO Coordinator at least once per month during the school year, or I will be placed inactive and will not have access to any of the services or benefits of the program.

FINAL CERTIFYING STATEMENT
My signature below indicates that the information given on this application is true and complete to the best of my knowledge. I also certify that the deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. Additionally, I understand that the information given herein is for the receipt of services funded by a Federal grant. The information provided may be disclosed to third parties for the purpose of verifying eligibility requirements, and in an effort to prevent fraud, waste and abuse in providing federal assistance.

Applications can be submitted the following ways:
1. Email (please scan, no smartphone pictures) to: Cindy.Bunton@DaytonaState.edu
2. If instructed, give to your child’s teacher or guidance counselor
3. Mail or deliver to TRiO Talent Search (see DSC Flagler/Palm Coast address below)