Bibb Application

Epsilon Beta Lambda & Alpha Phi Alpha- TRIO Programs

This is a FREE program for middle and high school students at targeted schools sponsored by a grant from the U.S. Department of Education. The program provides academic, career, and financial counseling to all participants and encourages them to graduate from high school and continue on to and graduate from college. Program services include: tutoring, counseling, college application assistance, scholarship and financial aid assistance, SAT/ACT prep, college tours and other educational field trips. All interested students must complete an application to be considered for enrollment. Please have a parent present to help complete the application.
School*

Westside High SchoolCentral High SchoolNortheast High SchoolMiller Middle SchoolWeaver Middle SchoolOther
Student Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Gender*
E-mail Address*
example@example.com
Mobile Number*

Area CodePhone Number
Citizenship*

U.S. CitizenPermanent Resident/ Eligible Non-Citizennon- U.S. Citizen
Ethnic Group*

African American/ BlackCaucasian/ WhiteLatino/ HispanicNative AmericanOther
Are you physically challenged?*

NoYes- VisualYes- MobilityYes- HearingYes- Learning Disability
Grade*

SixthSeventhEightNinthTenthEleventhTwelth
Services Offered (Please Select All That Interest You)*

Academic AdvisingSummer ActivitiesCareer CounselingTutoringCareer Planning & ExplorationCollege Planning & ExplorationFinancial Aid & Scholarship InformationCollege Visits & Cultural Field TripsComputer & Other Technology Access
What are your plans after graduating high school?*

Go directly to CollegeGo to Trade SchoolGet a JobJoin the MilitaryI am undecided about my plans after graduating from high school

Please list two teachers who would give you a recommendation to be in this program: *

	Last Name	Class Subject
1
2

Please tell us a little about yourself and your life goals. (Please write at least 4 sentences)*
Parent's Information

A parent or legal guardian will need to complete this portion of the application.
Parent's Name*

First NameLast Name
Parent's Phone Number*

Area CodePhone Number
Parent's Email*
example@example.com
Number of people who Live in Your Household*

12345678Other
Parent's Education Level*

Some High SchoolHigh School GraduateSome CollegeAssociate's DegreeBachelor's Degree
Parent's Marital Status*

MarriedSingleDivorcedSeparatedWidowedOther
Parent's Annual Income*

$0- $17,655$17,656- $23,895$23,896- $30,135$30,316- $36,375$36,376- $42,615$42,616- $48,855$48,856- $55,095$55,096- $61,335Over $61,335
Do you the parent, file taxes?*

YesNo
Does your child qualify to receive Free or reduced lunch at school?*

YesNo
Does your family qualify to receive assistance from any of the following sources?*

Aid the Families with Dependent Children (DFAC)Social SecurityVeteran's BenefitsFood Stamps/ TANFUnemploymentNone of these
Parent's Signature- By signing below, you verify that the above information and income data is correct to the best of your knowledge. Furthermore, your signature verifies your understanding that all information you have provided is confidential.*

Clear
I, Parent's Name* do authorize the staff of the Epsilon Beta Lambda & Alpha Phi Alpha- TRIO Programs to obtain copies of Student's Name* transcripts, report cards and all test scores throughout his/her high school years. I understand that this information will be held in strict confidence and will be used to evaluate my child’s progress to determine the effectiveness of the services rendered by the Epsilon Beta Lambda Educational Talent Search TRIO Program.

In addition, I hereby authorize any school, college/university, or third-party entity to release any academic or financial aid information (to include a copy of our application for free and reduced meals) from my files that is requested by the Epsilon Beta Lambda Educational Talent Search TRIO Program. All information obtained by the program mentioned above is completely personal and confidential and is only used for verification of eligibility or enrollment in postsecondary institutions.
Signature*

Clear
Should be Empty:

Epsilon Beta Lambda & Alpha Phi Alpha- TRIO Programs

Parent's Information