Con Mi MADRE Success Application

2023-2024 Success Application
Student Name*

First NameMiddle NameLast Name
Current Institution Attending*
Type NA if not enrolled
Declared Major/ Minor*
Type NA if not enrolled
Classification*

FreshmanSophomoreJuniorSeniorGetting certification/licencse
When do you expect to complete your degree?*
Include semester and year. Ex: Spring 2020
What High School did you graduate from?*
What year did you graduate HS?*
What was your HS GPA?*
Date of Birth*

MonthDayYear
Date
Country of Birth*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What was your first language?*
Are you a first generation college student?*

YesNoI am not sure
Did you receive free or reduced lunch in HS?*

YesNoI am not sure
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email*
example@example.com
Student Mobile #*
Please enter a valid phone number.
Student Race/Ethnicity (check all that apply)*

Asian/Asian AmericanBlack/African AmericanHispanic/Latino(a)(e)Native American/Alaska NativeNative Hawaiian/Pacific IslanderWhite
Student Hispanic/Latino Origin (check all that apply)*

Does not applyMexican/Mexican AmericanCuban/Cuban AmericanPuerto RicanOther
What are your pronouns? (check all that apply)*

She/herHe/hisThey/themI prefer not to answerOther
How do you currently identify your gender? (check all that apply)*

Male/ ManFemale/ WomanNonbinaryI prefer not to answerOther
Do you consider yourself a member of the LGBTQIA+ community?*

YesNoI prefer not to answer
Primary Parent/Guardian Contact

This contact will serve as the primary contact for the student during emergencies or outreach attempts.
Parent Name*

First NameMiddle NameLast Name(s)
Relationship to Student*

MotherFatherGuardianOther
Preferred Language*

SpanishEnglishBothOther
Parent Email
example@example.com
Parent Mobile #*
Please enter a valid phone number.
Parent Date of Birth

MonthDayYear
Date
Country of Birth

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation
Parent Race/Ethnicity

Asian/Asian AmericanBlack/African AmericanHispanic/Latino(a)(e)Native American/Alaska NativeNative Hawaiian/Pacific IslanderWhite
Parent Hispanic/Latino Origin

Does not applyMexican/Mexican AmericanCuban/Cuban AmericanPuerto RicanOther
Parent's Highest Education Level Completed

No schoolElementary schoolMiddle schoolHigh school/GEDSome CollegeCertificationAssociate's or Bachelor's DegreeGraduate Degree
Household Information
What language is primarily spoken in your family?

EnglishSpanishBothOther
Has anyone in the household participated in Con Mi MADRE before?*

Yes, in the pastYes, a sibling is currently in the programNo
Select all who live in your family's household.

MotherFatherGrandmotherGrandfatherSiblingsOther
What are your parents' household income?

Less than $10,000$10,000 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000 - $59,999$60,000 - $69,999$70,000 - $79,999$80,000 - $89,999$90,000 - $99,999$100,000 - $149,999More than $150,000

Authorization to Participate
Liability Agreement*

I hereby understand that I consent to relieve and release Con Mi MADRE, its sponsoring and participating universities, colleges, school districts, organizations, and their respective officers, employees, and agents, together with all those persons assisting with any phase of all program activities(excluding paid certified carriers) from any and all liability, responsibilities for making trips and activities and hereby releases all of said parties from all liability by reason of any accident, injury or other harm that I may suffer while on any trip or while participating in any program activities. I understand that I have agreed to indemnify and hold all of said parties harmless from all claims hereafter made by or asserted on behalf of the student named above.
Participation Responsibility*

I understand that Con Mi MADRE has the authority to terminate services to me if I choose to be inactive in Con Mi MADRE activities for more than a year.
Data Reporting and Privacy*

I understand that I will be asked to provide feedback and complete assessments throughout the year for programmatic evaluation purposes. My name will never be associated with any information reported, and all personal identifying information will be kept separate from the information shared when completing Con Mi MADRE surveys. I know that I can refuse to complete these evaluations at any time, and it will not affect my enrollment in the program.
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*

I grant permisionI do NOT grant permission
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.
Limits of Confidentiality*

By checking this box, I am agreeing to the above limits of confidentiality and understand their meaning and ramifications.
Student Full Name*

First NameLast Name
Student Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

2023-2024 Success Application

Primary Parent/Guardian Contact

Household Information

Authorization to Participate

Non-Fee/Photo Release