VUU TRiO Educational Talent Search Application

Student Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Email Address*

example@example.com

Student Cell Phone Number

Student's Birthday*

Date

Do you consider yourself Hispanic or Latino?*

YESNO

If 'NO,' please check the option that applies.

Are you a U.S. Citizen*

YESNO

If 'NO,' what is your Permanent Resident A# or an Eligible Non-CItizen A#?

A#

Student's Gender*

FemaleMaleNon-BinaryPrefer not to say

Which school do you currently attend?*

If "Other," what school do you currently attend?

What grade are you in for this school year?*

9th10th11th12th

Are you currently enrolled in Upward Bound or any other TRiO Programs?*

YESNO

Why are you interested in joining TRiO?*

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email Address*

example@example.com

Parent/Guardian Phone Number*

Secondary Parent/Guardian Name

First NameLast Name

Secondary Parent/Guardian Email Address

example@example.com

Secondary Parent/Guardian Phone Number

What is the number of people living in your home, including yourself?*

Household size

Indicate your Family/Household taxable income (line43 of the IRS 1040 form, line 27 of the 1040A, or line 6 on the 1040EZ). Please refer to or submit a copy of your last year’s tax form showing taxable income line. *

Household yearly taxable income.

Did the mother of the student earn a college degree?*

Did the father of the student earn a college degree?*

With my signature below (parent’s signature needed only if the student is under 18 years of age), I hereby grant permission to the VUU ETS staff to access: Copies of my/my child’s school and other partnering agency records including but not limited to: class schedule, grades, transcripts, Virginia SOL scores, Free & Reduced Lunch eligibility information, address, phone numbers, suspension & disciplinary records, ADA information, SAT/ACT scores, and other pertinent information.

I hereby authorize post-secondary institutions to release to the VUU ETS staff copies of my/my child’s college academic and enrollment information, as well as all student aid awards at the chosen colleges(s) after high school until the completion of a certificate/degree from a postsecondary institution

Records will be used to assess student needs, monitor student progress, document eligibility for the program, tracking and for additional reporting purposes as needed. All information will remain confidential. This information shall only be transferred to a third party, outside of the VUU ETS program on the condition that the written consent of the parents/guardians (or applicant over 18) is first obtained.

ACTIVITIES/PROMOTIONAL RELEASE

As a parent/guardian signing this form, I give permission for my child to participate in educational program-sponsored activities. I also give permission for the use of my child’s name and/or photograph for editorial. Promotional, recruitment, and/or educational purposes. I will do my best to encourage and participate in my child’s ETS activities

STUDENT AGREEMENT

If accepted to the VUU ETS program, I agree to attain all personal, academic, and career goals that I and the VUU ETS staff set for my growth and personal development. I will do my best to attend all programs, meetings, and activities. Students are expected to follow the same rules of conduct and dress code established by the school district. This includes 1) no alcohol, drugs, or tobacco products at any time; 2) No profanity or horseplay at any time; and 3) Fighting and disrespectful behavior towards VUU ETS staff and others will not be tolerated. I further agree to treat myself, and others with respect and be a positive representative of the VUU ETS program. Students violating this policy shall be subject to disciplinary sanctions which may include suspension and/or removal from the VUU ETS program.

Parent/Guardian Signature*

Parent/Guardian Name*

First NameLast Name

Date*

Date

Student Signature*

Student Name*

First NameLast Name

Date*

Date

Virginia Union University TRiO Educational Talent Search Program

Section I:

Section II:

Section III: