NACEE Student Profile Form

Family Information

Parent(s)/Legal Guardian(s)
Mother's/Guardian Information
Relationship to student:*
Mother/Guardian/Grandmother/Etc.
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
All parents/guardians of applicants MUST have an email address
Cell Phone Number *
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Does Mother currently hold a High School Diploma or GED?*

YesNo
Does Mother currently hold a Bachelor's Degree (4-year degree)?*

YesNo
Which college or university?*
Father's/Guardian Information
Relationship to student:*
Father/Guardian/Grandfather/Etc.
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
E-mail
All parents/guardians of applicants MUST have an email address
Cell Phone Number
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Does Father currently hold a High School Diploma or GED?*

YesNo
Does Father currently hold a Bachelor's Degree (4-year degree)?*

YesNo
Which college or university?*

Emergency Contact/Release of Records
Person(s) authorized with whom child may be released:
First and Last Name / Relationship to Applicant
Emergency Contact when a Parent/Guardian cannot be reached:
Emergency Contact Name

First NameMiddle NameLast Name
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Release of Academic and School Records
I authorize the North Alabama Center for Educational Excellence (NACEE) Emerging Scholars Program to obtain and receive copies of my student's academic records, counselor's reports, and any other academic information necessary to complete the program's application. These documents include, but are not limited to: School records Transcripts Standardized test scores Information on the student’s status and performance Student’s contact information Warning/Failure notices Registration forms Academic awards Any other academic or behavioral documents necessary for evaluating and/or keeping track of your student's academic progress I have carefully read this Release form before signing it. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. This agreement shall become effective only upon receipt by the North Alabama Center for Educational Excellence and shall be governed by the laws of the state of Alabama.*

YesNo
I give NACEE permission to record the image and/or voice of the minor named above, and I grant NACEE all rights to use these sounds, still, or moving images in any medium for educational, promotional, advertising, or other purposes that support the mission of the Emerging Scholars Program. I agree that all rights to the sound, still, or moving images belong to the Emerging Scholars Program.*

YesNo
I give permission for my child to be interviewed, identified, and/or photographed/filmed for use in program publications, including, but not limited to, publication via web site or other digital publications, videos, newspapers, radio, or television. By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.*

YesNo
Current School:*
Print Applicant Name*
Applicant Signature*
Print Parent/Guardian Name*
Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
Should be Empty:

North Alabama Center for Educational Excellence (NACEE)

Student Information

Family Information

Mother's/Guardian Information

Father's/Guardian Information

Emergency Contact/Release of Records

Release of Academic and School Records