• Student Intake & Consent Form

    This application is for Workforce, Employment, and Education Assistance *PLEASE COMPLETE INFORMATION TO THE BEST OF YOUR KNOWLEDGE*
  • Application Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 00-0000.
  • Gender*
  • Format: (000) 000-0000.
  • Ethinicity*
  • Race*
  • Family Type*
  • Education*
  • Have you served in the military?*
  • Are you disabled?*
  • Health Insurance*

  • Income

  • Employment*

  • You are REQUIRED to provide YOUR income verification through any of the following:

    • Pay stubs (last 30 days)
    • DIS (last 30 days)
    • Employer letter (last 30 days)
    • SSI/SSD payment sheet
    • Other
  • Income*
  • Does anyone in your household have any of the following?*
  • Have you or anyone in your household received services through Transcend STEM Education before?*

  • Other Household Members

  • In this section please list ALL OTHER MEMBERS of the household*
  • OTHER HOUSEHOLD members Income*

  • You are REQUIRED to provide income verification for ALL OTHER HOUSEHOLD MEMBERS over 18 years old receiving income through any of the following:

    • Pay stubs (last 30 days)
    • DIS (last 30 days)
    • Employer letter (last 30 days)
    • SSI/SSD payment sheet
    • Other

  • Expenses


  • Car Payment:      
    Groceries:      
    Miscellaneous:      
    Rent:      
    Car:      
    Insurance:      
    Mortgage:      
    Gasoline:      
    Maintenance:      
    Other:      

  • Barriers

  • Barriers for other Household Members*
  • Check all barriers present:*

  • Domestic Violence

  • Domestic Violence*

  • Consent To Release Information

  • "I,   *   *   , give Transcend STEM Education consent to release, obtain, and share all pertinent identifying and non-confidential social, medical, and other information about myself that will allow me to benefit from services offered. In granting such permission, I understand that such information will remain confidential and that such information will only be used for my benefit or to benefit other members of my family.
    The statements made by me on this consent for are true, correct, and complete to the best of my knowledge"

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Self Sufficiency Plan

  • Self-sufficiency Statement 

     "Self-sufficiency" is defined as: 

    The applicant being able to achieve (or work towards) a set of goals which will result in greater self-sufficiency and eliminate some of the causes of poverty and other issues applicants may be facing. What resources are applicants (or community agencies the family is wokring with) bring to address these issues.

  • Transportation

  • Are you able to utilize a transit source? *(if*

  • Scholarship Program

  • Have you applied for Educational Financial Assistance somewhere else?
  • Will certification/education allow you to provide for yourself?

  • Client Application Acknowledgement

  • Transcend STEM Education Program partners with several organizations including social media and public services to assist families experiencing a housing crisis, unemployment, career changes or needing educational assistance. This application is designed to collect data,  permit Transcend STEM Education store securely, and to share only as needed with autorized personnel under encryption client information inr order to collaborate on services and to promote client stability.

  • By signing below, I acknowledge that I have read and understood and I  provide Transcend STEM Education permission to obtain, share and utilize information as it relates to my specific needs.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Privacy Policy and Termination Disclosure Statement

  • Information to be released: I understand authorized personnel will share client infromtion needed for service, delivery, program eligibility, to track demographic trends, service patterns and the cleint outsomce achieved.

    For the purpose of: I understand this is for the purpose of (a) providing coordinated housing, medical, social, psychological, and other service to me, (b) evaluating the outcomes related to service delivery, and (c) to improve coordiantion of services to assist individuals and families experincing a crisis, and (d) to identify barriers and service gaps that block the path out of poverty. In the event of the publication of the results of the program, my identity will be kept confidential, although information about my circumstances may be discussed. 

    Right to revoke: I understand this authorization is subject to revocation at any time except to the extent that the agencies which are to make the disclosures have already taken action in reliance on those disclosures. 

    Potential Re-Disclosure: I understand that information that I authorize to be disclosed may be re-disclosed and not subject to medical privacy regulations.

    Program Rules Privacy Policy and Termination Policy:

    I understand that there are Program Rules to be adhered to and by signing below I acknowledge receipt of the Program Rules, Privacy Policy, Termination Policy and Grievance procedures.

     By signing below, I acknowledge receipt of privacy policies and termination disclosure and I understand the information provided.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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