• TRIO Talent Search Application

  • Address: 704 Coyote Trail, Alice, Texas 78333
    Email: talentsearchalice@coastalbend.edu Office: (361) 664-2981 Ext. 3081

    • STUDENT INFORMATION 
    • BIRTHDATE: *
       - -
      2 digit month, 2 digit day, 4 digit year
    • GENDER:*
    • MAY TALENT SEARCH CONTACT YOUR STUDENT VIA CELL PHONE?*
    • CHECK ALL PORTIONS OF THE LATEST STAAR EXAM YOU HAVE TAKEN:*
      Rows
    • WHAT HIGH SCHOOL ACADEMIC TRACK ARE YOU PURSUING?*
    • ARE YOU IN DUAL ENROLLMENT CLASSES?*
    • ARE YOU AT RISK OF FAILING?*
    • DO YOU PLAN ON ATTENDING COLLEGE?*
    • EXTENUATING PERSONAL SITUATION: FOSTER CHILD, ORPHAN, HOMELESS, STUDENT WITH A DISABILITY, ETC?*
    • DO YOU NEED ASSISTANCE WITH ANY OF THE FOLLOWING: (Check all that apply)*
    • ETHNICITY: (CHECK ALL THAT APPLY)*
    • IS STUDENT A U.S. CITIZEN?*
    • IS STUDENT CURRENTLY PARTICIPATING IN ANOTHER TRIO PROGRAM?*
    • DOES STUDENT HAVE CHILDREN?*
    • STUDENT LIVES WITH:*
    • PARENT/GUARDIAN INFORMATION 
    • DO YOU HAVE A BACHELOR'S DEGREE OR HIGHER?*
    • DO YOU HAVE A BACHELOR'S DEGREE OR HIGHER?*

    • EMERGENCY CONTACT

    • INCOME AND FAMILY VERIFICATION 

    • WE ARE REQUIRED TO USE THIS INFORMATION TO PROCESS YOUR APPLICATION. ALL INFORMATION IS STRICTLY CONFIDENTIAL AND IS USED ONLY TO DETERMINE ELIGIBILITY FOR TALENT SEARCH SERVICES.

      PLEASE PROVIDE INFORMATION FOR THE LAST TAX YEAR.

    • ARE YOU LIVING ON A FIXED INCOME?*
    • DOES ANYONE IN THE HOUSEHOLD RECEIVE ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY)*
    • TAX FILING STATUS:*

    • I hereby certify that the information provided in the income statement is true, complete, and accurate to the best of my knowledge. I understand that I may be required to provide supporting documentation upon request. I further acknowledge that failure to produce such records may result in program disqualification.

    • DATE:*
       - -
      2 digit month, 2 digit day, 4 digit year
    • PARENT/STUDENT CONSENT FOR SERVICES  

    • 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)*

    • 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.

    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • FERPA Consent to Release Student Information 

    • 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)*
    • The information is to be released for the following purpose: (check all that apply)*

    • 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.

    • I hereby authorize the release of my education and employment records to the TRIO Talent Search program. The type of information that is to be released under this consent form includes:

    • I hereby authorize the release of my education and employment records to the TRIO Talent Search program. The type of information that is to be released under this consent form includes:

      • Transcripts
      • Progress Reports
      • School enrollment status
      • School credits completed
      • Degrees earned
      • Disciplinary records
      • Recommendations for employment or admissions to schools
      • Other information related to education and work performance

    • The above information is to be released for the purposes of verifying placement and retention in college and/or employment and for Career and Education Services staff to provide support with retention in college and employment. This information will only be shared with program staff and program funders. I understand that the information may be released orally or in the form of copies of written records, as preferred by the requester. I understand that I have a right to inspect any written records released pursuant to this Consent. 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 for a year after I graduate, and my educational and employment records will continue to be provided to the TRIO Talent Search program for the specific purpose described above.

    • Date *
       - -
      2 digit month, 2 digit day, 4 digit year
    • Date *
       - -
      2 digit month, 2 digit day, 4 digit year
    • Submit 
    • Should be Empty: