Con Mi MADRE Success Application

  • Con Mi MADRE Success Application

  • Do you have a sister in Con Mi MADRE right now?*

  • Household Information

  • What language is mostly spoken at home?
  • County
  • Do both parents live at home?
  • What are your parents' household income?

  • Student Information

  • What are your pronouns? (check all that apply)*
  • Classification*
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
  • Student Race/Ethnicity (check all that apply)*
  • Student Hispanic/Latino Origin (check all that apply)*
  • How do you currently identify your gender? (check all that apply)*
  • Do you consider yourself a member of the LGBTQIA+ community?*
  • Are you a first generation college student?*
  • Did you receive free or reduced lunch in HS?*
  • How will you be paying for your college or training education? (check all that apply)*

  • Primary Parent/Guardian Contact

    This contact will serve as the primary contact for the student during emergencies or outreach attempts.
  • Relationship to Student*
  • Preferred Language*
  • Format: (000) 000-0000.
  • Parent Date of Birth
     - -
  • Parent Race/Ethnicity
  • Parent Hispanic/Latino Origin
  • Parent's Highest Education Level Completed
  • Would you like us to send your parent information about future events and support we offer to parents?*

  • Authorization to Participate

  • Non-Fee/Photo Release

    Con Mi MADRE requests permission to reprint photographs of participants to be used for Con Mi MADRE publications, websites, electronic and digital media, educational projects or purposes, publicity, or advertising. Understand that names may be used for picture captioning purposes when necessary. All images will remain property of Con Mi MADRE.
  • Non-Fee/Photo Release*

  • Limits of Confidentiality

    All interactions with Con Mi MADRE coordinators and interns are considered to be confidential. The only way confidentiality is breached without permission is if there is reason to believe that abuse, neglect, or exploitation may have occurred within the family or the student.

    Duty to Warn and Protect
    When it is disclosed that one has intentions or a plan to harm another person, the professional may warn the intended victim and will report information to legal authorities. In cases in which the clients disclosed or implies a plan for suicide, it is required to notify legal authorities and make reasonable attempts to notify the family. 

    Abuse of Children and Vulnerable Adults
    If a one states or suggests that they are abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the professional is required to report this information to the appropriate social services and/or legal authorities. 

    Prenatal exposure to Controlled Substances
    Professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

    Minors/ Guardianship
    Parents or legal guardians of non-emancipated minor students have the right to access records.

  • Date*
     / /
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  • Should be Empty: