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FillableETSStudentApplication12-17-2018 Educational Talent Search

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Pg. 1
TRiO Programs are funded by the United States Department of Education Revised, 12/17/2018
Central Connecticut State University
2018-2019 TRiO Educational Talent Search Enrollment Application
Mission Statement:
The TRiO Educational Talent Search (ETS) program provides students with academic assistance and support, college
preparation and exposure, career development, and cultural enrichment. Once a student has been accepted into TRiO ETS,
there is no need to apply again for the program. Students stay enrolled in TRiO ETS until they graduate from high school or
the student moves out of the Consolidated School District of New Britain.
The information you provide is private and used solely to determine eligibility, report data, and track student success.
Please visit our website at http://www.ccsu.edu/trio
for more information regarding programming.
BRING OR MAIL APPLICATION TO:
The main office in your student’s school or to TRiO Director, Office of TRiO Programs at Central Connecticut State
University, Institute of Technology and Business Development, 185 Main Street, Suite 218, New Britain, CT. 06051 or
Fax to: 860-832-2235. You can also scan and email this application to TRiO Director, Andres Sovero, at
soveroa@ccsu.edu
. Actual Signatures are required for this application to be processed.
STUDENT INFORMATION – CONFIDENTIAL, Please print using a black or blue pen.
Name of Student: ________________________________________________________________________________________
(First) (Middle Initial) (Last)
Mailing Address (include Floor or Apt #):
New Britain, CT. Zip Code: Email:
(1) Home Phone: (2) Cell Phone:
Gender: □ Male □ Female Marital Status: □ Single □ Married □ Divorced Date of Birth: ______ /_____ /_______
Ethnic Background:
MM DD YYYY
□ Hispanic/Latino □ American Indian or Alaska Native, non-Hispanic/Latino □ Asian, non-Hispanic/Latino □ Black or African
American, non-Hispanic/Latino □ White, non-Hispanic/Latino □ Native Hawaiian or Other Pacific Islander, non-
Hispanic/Latino □ Two or more races, non-Hispanic/Latino □ Race or Ethnicity Unknown
U.S. Citizen? □ Yes □ No or Permanent Resident? Green Card #:
U.S. Veteran? □ Yes □ No
Are you currently enrolled in another TRiO Program (Upward Bound Math Science)? □ Yes □ No
EDUCATION INFORMATION – CONFIDENTIAL
Name of School: Current Grade Level: GPA:
(18-19 school year) (6
th
- 12
th
) (18-19 school year)
Name of Counselor: Student ID:
Do you want to go to college? □ Yes □ No □ Not Sure If Yes, Name of College: ___________________________________
Alternate Education: □ Out of school □ CDP □ GED □ Adult Ed □ Other: ________________________________
■
Pg. 2
TRiO Programs are funded by the United States Department of Education Revised, 12/17/2018
ELIGIBILITY INFORMATION– CONFIDENTIAL
Parent/Guardian #1 Name and Phone Number:
Parent/Guardian #2 Name and Phone Number:
Parent/Guardian #1 & 2 Emails: _____________
Language spoken in the home: □ English only □ English and
□ Only a language other than English (specify)
Required - Does Parent/Guardian #1 have a U.S. four-year college degree (B.A. or B.S.): □ Yes □ No □ Not Sure
Required - Does Parent/Guardian #2 have a U.S. four-year college degree (B.A. or B.S.): □ Yes □ No □ Not Sure
FINANCIAL INFORMATION – CONFIDENTIAL
Answer Section A or B below, but not both
A Total number of exemptions claimed on Federal 1040/1040A/1040EZ tax form (including applicant):
Taxable Income from the most recent Federal 1040/1040A/1040EZ tax form: (Do not use Adjusted Gross Income
for the table below; use “Taxable” Income - found on page 2 of the 1040 tax return)
OR
B I did not file Federal 1040/1040A/1040EZ taxes but my income is: $ per: □ week □ month □ year
My income is from (check all that apply) □ Job □ Unemployment □ TANF □ Disability □ Other
**Required**: Total number of family members living at home (including applicant): ___________
ADDITIONAL INFORMATION – CONFIDENTIAL
AGREEMENTS AND RELEASES
ETS SERVICES
□ $0 – $18,210
□ $31,171 – $37,650
□ $50,611 – $57,090
□ $18,211 – $24,690
□ $37,651 – $44,130
□ $57,091 – $63,570
□ $24,691 – $31,170
□ $44,131 – $50,610
□ $63,571 – Over
My student requires special accommodations to participate in activities outside of the school:
□
Yes
□
No
If yes, describe:
My student has the following medical conditions: (Please describe): ______________
My student is allergic to the following medications, foods and/or substances (Please list): ______________
Please check TRiO ETS services needed or wanted: (Select Multiple)
□ Middle School Activities
□ Financial Aid Application Assistance
□ Career Exploration
□ Application Fee Assistance/Waiver
□ Academic Counseling
□ College Entrance Exams Preparation
□ College Visits
□ Financial Aid/Scholarship Information
Pg. 3
TRiO Programs are funded by the United States Department of Education Revised, 12/17/2018
PHOTOGRAPHY AGREEMENT AND RELEASE
I authorize the use of my student’s/my photo by ETS for publicity and recruitment purposes for the duration of their/my
involvement in the ETS program. □ Yes □ No
STUDENT SIGNATURE: Date
PARENT/GUARDIAN SIGNATURE: Date
******************************************************************************************************
RELEASE OF RECORDS
Students Name (print): School:
The Release of Records is essential and required for TRiO Educational Talent Search (ETS) staff to provide appropriate services. The
information requested will be relative to and consistent with my student’s/my education. Such information may include, but is not
limited to copies of school transcripts, test scores, free and reduced lunch eligibility, class schedules, attendance and financial aid
information for as long as my student is/I am enrolled in the ETS program. I authorize the representatives of my student’s/my
secondary school to release said records to the ETS staff for purposes stated above.
Further, we/I authorize ETS representatives to communicate with representatives from postsecondary institutions on my student’s/my
behalf for up to six-years after high school graduation. This also authorizes the postsecondary institution in which my student/I am
enrolled to release information on admissions, college academic enrollment and financial aid information including award letters.
This information is used to best determine program services specific to my student’s/my needs for educational progress, program
reporting and verification of postsecondary completion. This information is private and protected under the General Education
Provision Act, as well as the Family Education Rights and Privacy Act. Should you choose not to sign this Release of Records, ETS
may not be able to serve your student/you, or program services may be limited.
Student Signature Date
Parent/Guardian Signature (if student is under 18) Date
Federal and state laws do authorize the release of private information without your consent to school officials who have legitimate
educational interests in the information; the US Department of Education for the purposes of program compliance; evaluation; in
connection with a subpoena if necessary, to protect your health or safety or the health or safety of others; or if required by a court
order.
******************************************************************************************************
STUDENT & PARENT/GUARDIAN AGREEMENT
I, the undersigned, confirm that all the information on this application is true to the best of my knowledge. Further, if my student is/I
am accepted into the TRiO ETS program, I agree to meet with ETS Staff regularly, do my best academically and prepare to enter a
Trade School; Technical, 2-Year or 4-Year College after high school.
STUDENT SIGNATURE: Date
PARENT/GUARDIAN SIGNATURE: Date
FOR OFFICE USE ONLY:
U.S. Citizen or Permanent Resident Submitted all signed documents __________ Student Need
Completed 5
th
Grade, 11-27 years old, OR meets criteria for adult participation Missing signed Documents
*********************************************************************************************************************************************************************
□ LI/FG □ LI □ FG □ OTHER Verified
*********************************************************************************************************************************************************************
□ Add □ Waiting List □ Pending □ Not Eligible (Reason)
*********************************************************************************************************************************************************************
ETS Staff Initials Date Director’s Initials Date
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Completed 9 March 2020

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