Coastal Bend College-TS 2-2025 Application Form

2025-2026 TRIO Talent Search Application
Address: 704 Coyote Trail, Alice, Texas 78333
Email: talentsearchalice@coastalbend.edu Office: (361) 664-2981 Ext. 3081

STUDENT NAME: *

First NameLast Name
Social Security #:*
999-99-9999
MAILING ADDRESS: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT CELL PHONE: *
(999)999-9999
STUDENT CELL PHONE:*
(999)999-9999
STUDENT EMAIL:*
example@example.com
BIRTHDATE: *

MonthDayYear
mm-dd-yyyy
CURRENT AGE: *
GENDER:*

MaleFemale
HIGH SCHOOL ATTENDING: *
CURRENT GRADE: *
GRADUATION YEAR: *
STUDENT ID #: *
MAY TALENT SEARCH CONTACT YOUR STUDENT VIA CELL PHONE?*

YesNo

CHECK ALL PORTIONS OF THE LATEST STAAR EXAM YOU HAVE TAKEN:*

Rows	PASSED	NOT PASSED	NOT TAKEN
READING
WRITING
MATH
SCIENCE
HISTORY

WHAT HIGH SCHOOL ACADEMIC TRACK ARE YOU PURSUING?*

REGULAR HS DIPLOMARECOMMENDED HS DIPLOMADISTINGUISHED HS DIPLOMA
ARE YOU IN DUAL ENROLLMENT CLASSES?*

YesNo
ARE YOU AT RISK OF FAILING?*

YesNo
DO YOU PLAN ON ATTENDING COLLEGE?*

YesNo
EXTENUATING PERSONAL SITUATION: FOSTER CHILD, ORPHAN, HOMELESS, STUDENT WITH A DISABILITY, ETC?*

YesNo
DO YOU NEED ASSISTANCE WITH ANY OF THE FOLLOWING: (Check all that apply)*

COLLEGE CLASS SELECTION AND ADMISSIONS APPLICATIONCAREER SELECTIONFINANCIAL AIDSCHOLARSHIP SEARCHACADEMIC SUPPORTTUTORING
ETHNICITY: (CHECK ALL THAT APPLY)*

ASIANAFRICAN AMERICANHAWAIIAN/ PACIFIC ISLANDERHISPANIC/LATINONATIVE AMERICAN/ ALASKA NATIVEWHITE/CAUCASIANAMERICAN INDIANOther
PRIMARY LANGUAGE SPOKEN AT HOME?*
IS STUDENT A U.S. CITIZEN?*

YesNo
IS STUDENT CURRENTLY PARTICIPATING IN UPWARD BOUND?*

YesNo
DOES STUDENT WORK? IF SO, HOW MANY HOURS PER WEEK? *
DOES STUDENT HAVE CHILDREN?*

YesNo
STUDENT LIVES WITH:*

FATHERMOTHERGRANDPARENT(S)Other

MOTHER/GUARDIAN NAME: *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT NUMBER: *
(999)999-9999
EMAIL: *
example@example.com
DID YOU GRADUATE FROM A 4-YEAR COLLEGE?*

YesNo
EMPLOYER:*
FATHER/GUARDIAN NAME: *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT NUMBER: *
(999)999-9999
EMAIL: *
example@example.com
DID YOU GRADUATE FROM A 4-YEAR COLLEGE?*

YesNo
EMPLOYER:*
EMERGENCY CONTACT
NAME: *

First NameLast Name
PHONE NUMBER:*
(999)999-9999

CONSENT FOR SERVICES/TREATMENT:

I understand Talent Search services including but not limited to: academic advising, tutoring referrals, cultural enrichment activities, career and college exploration; will be provided as needed. Services are provided by Talent Search (TS) staff (advisors, volunteers, mentors, tutors, and teachers), and are designed to help students achieve their academic and personal goals. These services are provided free of charge and at the student’s will.

I authorize diagnostic medical and/or surgical treatment on my child as may be deemed medically necessary in order to assure the safety of my child. It is distinctly agreed and understood that the attending physician and appropriate staff shall not be responsible in any way for any consequences from said diagnostic, medical and/or surgical treatment and is fully released from any and all claims and demands whatsoever which arise, grow out of or be incident to such diagnosis, treatment or surgery insofar as the law allows provided that these services are performed with ordinary care and the best of their ability. Talent Search does not provide payment for medical expenses.

BEHAVIOR AGREEMENT:

I understand that I am responsible for following both my school’s Student Code of Conduct and the TRIO Talent Search Student Code of Conduct during all Talent Search events and activities. The same expectations that apply at my school campus also apply while I am participating in the Talent Search Program. If any rule is broken, I understand that the TS staff may contact my parents, who will be required to pick me up immediately. I also acknowledge that failure to abide by either my school’s or the Talent Search Program’s Code of Conduct may result in my dismissal from the Coastal Bend College Talent Search Program.
COMMUNICATION & IMAGE (MEDIA) RELEASE: (CHECK ONE)*

I give permission to the Talent Search program to send communications via email, text message, school messenger (parent/guardian name), BAND app, my email, student email, cell phone, student cell phone, or home phone. I also permit the use of my child’s picture/image and/or accomplishments as a result of their participation in the program. These images or pictures may be used in program brochures, newsletters, flyers, or published on the program/college website to highlight activities and participation. I release any claims against Coastal Bend College, the Talent Search program, and/or its staff for any damages, awards, claims, or liabilities that may arise from any unauthorized or copyright violations involving my child’s image, picture, or work.I do not give Talent Search permission to contact my child via text messages or mobile apps, nor to use my child’s picture, image, and/or accomplishments resulting from their participation in the program.
By signing below, I acknowledge that I have read, understood, and agree to the above Consent for Services/Treatment, Behavior Agreement, and Communication & Media Release. I also affirm that all information provided in the application is accurate and true to the best of my knowledge.
PARENT SIGNATURE*

Clear
Date*

MonthDayYear
mm-dd-yyyy
STUDENT SIGNATURE*

Clear
Date*

MonthDayYear
mm-dd-yyyy

(Name of High School) *
Please provide information from the educational records of {main_name} requesting the release of educational records to:

Coastal Bend College - TRIO Talent Search

704 Coyote Trail,
Alice, Texas 78332
(361) 664-2981 Ext. 3081

(Note: Consent does not cover medical records held solely by Student Health Services or the Counseling Center – contact those offices for consent forms.)
The only type of information that is to be released under this consent is: (check all that apply)*

transcriptdisciplinary recordsrecommendations for employment or admission to other schoolsall recordsOther
The information is to be released for the following purpose: (check all that apply)*

family communications about university experienceemploymentadmission to an educational institutionOther
I understand the information may be released orally or in the form of copies of written records, as preferred by the requester. I have a right to inspect any written records released pursuant to this Consent (except for parents’ financial records and certain letters of recommendation for which the student waived inspection rights). I understand I may revoke this Consent upon providing written notice to TRIO Talent Search. I further understand that until this revocation is made, this consent shall remain in effect and my educational records will continue to be provided to TRIO Talent Search for the specific purpose described above.
Student Name*

First NameLast Name
Student ID*
Student Signature*

Clear
Date *

MonthDayYear
mm-dd-yyyy
Parent Name*

First NameLast Name
Parent Signature*

Clear
Date *

MonthDayYear
mm-dd-yyyy

2025-2026 TRIO Talent Search Application