Fillable Emporia State University TRIO McNair Scholars Program Application (Emporia State University)

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Emporia State University TRIO McNair Scholars Program Application (Emporia State University)

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Emporia State University
TRIO McNair Scholars Program
Application Cover Sheet
T
he Emporia State University TRIO McNair Scholars Program is seeking applicants! Qualified students who
are selected will participate in activities to prepare them for doctoral study. To qualify, students must meet the
following criteria:
1) Be first-generation student (neither parent completed a bachelor’s degree or, if you only lived with and
received support from one parent, that parent did not complete a bachelor’s degree) AND meet federal
income guidelines
OR
Be a member of a group that is underrepresented in graduate education as determined by the US
Department of Educati
on
AND
2) Be a US Citizen or permanent resident
3) Be at least a sophomor
e
4) H
ave a desire to pursue a research doctorate
ALL APPLICATION MATERIALS MUST BE COMPLETE FOR APPLICATION CONSIDERATION.
Mail application materials to:
TRIO McNair Scholars Program
Campus Box 4005
Emporia State University
1 Kellogg Circle
Emporia, KS 66801
Or hand-deliver application materials to:
TRIO Office – 323 South Morse Hall
Or submit application materials electronically to:
Dr. Shanna Eggers at seggers@emporia.edu
Phone: (620) 341-5097 Fax: (620) 341-5887 E-mail: seggers@emporia.edu
The TRIO McNair Scholars Program is funded by a grant from the US Department of Education.
TRIO McNair Scholars Application
Emporia State University
1 Kellogg Circle, Campus Box 4005 • 323 South Morse Hall • 620-341-5097
Part I: STUDENT DEMOGRAPHIC INFORMATION
Full Name:
Date of Birth:
Gender:
Male Female
ESU Student ID:
Cell Phone (primary contact number):
Home Phone or Parent Cell (secondary contact number):
Local (Emporia) Address:
Permanent Address:
Street:
Street:
City/State/Zip:
City/State/Zip:
ESU email:
Personal email:
Please mark your preferred contact method: phone call text message email
Citizenship: Please mark the item that best describes your citizenship status.
I am a citizen or national of the United States.
I am a permanent resident of the United States. (Please provide a copy of your alien registration card.)
I am in the US for other than a temporary purpose and will provide evidence from INS of my intent to become a permanent
resident.
I am a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands.
I am a resident of one of the Freely Associated States.
None of these statements applies to me.
Ethnicity (required by the US Department of Education)
Are you Hispanic/Latino Yes No
R
ace (required/defined by the US Department of Education; mark all applicable)
American Indian or Alaska Native
Asian
Black or African American
White
Native Hawaiian or Other Pacific Islander
Have you participated in any other TRIO programs?
Yes
No If yes, mark all that apply.
Student Support Services (SSS)
Upward Bound (UB)
Upward Bound Math/Science (UBMS)
Educational Opportunity Centers
Veterans Upward Bound
Talent Search
In what semester do you anticipate earning your bachelor’s degree? ___________________________________________________
What is your projected date of entry into graduate school? __
_________________________________________________________
De
gree(s) you ultimately intend to earn: bachelor’s only master’s doctorate (PhD/EdD) professional (MD/JD/DVM)
Part II: FAMILY EDUCATIONAL INFORMATION
With whom did you regularly reside and receive support from prior to age 18?
two parents mother only father only other: __________________________________________________________
Parent/guardian 1: father mother
Highest level of education completed by this parent/guardian:
less than high school
high school diploma/GED
some college
four-year college degree or higher
Par
ent/guardian 2: father mother
Highest level of education completed for this parent/guardian:
less than high school
high school diploma/GED
some college
four-year college degree or higher
Not applicable (single parent/guardian household)
Part III: FAMILY FINANCIAL INFORMATION
McNair is a federally funded program that requires income verification to comply with U.S. Department of Education regulations.
Eligibility for participation in McNair is based, in part, on household income from the prior tax year. The regulations vary from the
FAFSA, which uses tax information from two years ago. For the purposes of income verification for McNair, please provide the
following information. It will be held in the strictest confidence.
For federal financial aid purposes, are you considered a dependent or independent student? Dependent Independent
Please complete the appropriate section below based on your dependency status.
Dependent Students
What is the size of your parents’ household, including yourself? ________
Please have your pare
nt select and complete one of the following statements:
Please see the attached signed copy of the federal income tax form for the most recent tax year. Parent signature not required
below.
My parent(s) submitted a federal income tax return for the most recent tax year but respectfully declines to provide a copy. The
taxable income amount on the federal income tax return was $ ________________.
My parent(s) did not submit a federal income tax return for the most recent reporting year but attest that the family taxable
income was $ ________________.
___I understand that, if I am a dependent student, confirmation of family income will be required by a parent (see next page).
Independent Students
What is the size of your household, including yourself? ________
Select and complete one of the following statements:
Please see the attached signed copy of my federal income tax form for the most recent tax year.
I completed and submitted a federal income tax return for the most recent reporting year but respectfully decline to provide a
copy. The taxable income amount on the federal income tax return was $ ________________.
I did not submit a federal income tax return for the most recent tax year but attest that my taxable income was $ ____________.
_____________________________________ ________________
Student signature Date
Part IV: TRANSCRIPT
By signing the agreements below, you consent to McNair personnel obtaining your ESU transcript information. If you are a transfer
student, please provide an unofficial transcript from each institution you have attended.
Part V: UNDERSTANDING, AGREEMENT, AND CONSENT
Please read and initial each statement and then provide your signature to complete your application form.
___ To the best of my knowledge, all information provided in this application is true and correct.
___ I authorize the ESU TRIO McNair Scholars Program (McNair) to access my educational records and use information as
necessary to provide services and make reports to the U.S. Department of Education. I also authorize McNair to obtain reports
from my instructors regarding academic progress and the National Student Clearinghouse regarding enrollment and degree
information. I understand that all information will be kept confidential and used for the purposes of needs assessment, program
evaluation, federal reporting, and other administrative purposes. I understand that I will have access to all of my records
excluding letters of recommendation and mentor evaluations to which I have waived my right to access.
___ I recognize that, by federal law, the McNair Scholars Program must verify income-based eligibility and may contact the Office of
Financial Aid to verify dependency status. Further, I acknowledge that forms completed electronically requiring a parent’s
signature [for dependent students only] may require confirmation. I am providing the following email address that belongs to my
parent, ________________________________, for confirmation purposes only: _____________________________________.
parent name parent email address
___ I grant McNair permission to use photographs, video, quotes, academic accomplishments, statements, and/or my first and last
name in any/all McNair publications and electronic media.
___ I understand that some services offered by the McNair Scholars Program are required; these services include at least one
Honors Contract Course annually, participation in a Summer Research Internship, and advising each semester by my Faculty
Mentor and the McNair Scholars Program personnel. If selected as a Scholar, I will adhere to all requirements and strive to meet
all goals set forth in my individualized McNair Academic and Scholarly Achievement Plan through additional individual and group
services offered by the McNair Scholars Program.
___ I hereby release and hold blameless the State of Kansas, Kansas Board of Regents, Emporia State University, and their
employees from any and all claims and liabilities of any type whatsoever and for injury to or death which may now or hereafter
arise out of result from or be in any way connected directly or indirectly with the McNair Scholars Program and its activities.
I have read, agree with, and consent to these statements.
__________________________________________________________ _________________
Student Signature Date
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Completed 23 July 2020

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