Pipeline Student Application

Instructions for completeing this form:
1. Read each question carefully and complete all sections by writing in black or blue ink or typing on the computer.
2. If you fail to answer all necessary questions and/or omit signatures, your application will be returned to you for completion.
3. Students cannot participate in program activities until all application materials are complete and returned.
Name*

First NameLast Name
School Attending & Grade*
School ID #*
Social Security Number*
No spaces, only numbers.
Birthdate*

MonthDayYear
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student Cell Phone Number*

Area CodePhone Number
Student Email*
example@example.com
Gender*
Ethnicity*
Are you a US Citizen?*

YesNo
Do you have a computer with internet access at home? *

YesNo
Parent/Guardian Information
Parent or Guardian's Name*

First NameLast Name
Relation to child*

MotherFatherGrandparentGuardianOther
Phone Number*

Area CodePhone Number
Email*
example@example.com
Has parent/guardian received a 4-year degree?*

YesNo
If yes, name of college/university
Number of people living in your household*
What is your yearly household income?*
Media Publication and Release Authorization
I hereby grant PipeLine Program of BGCTNV full and absolute permission to publish, display, and use of photographs, together with descriptive text or statements, in which I or my child appear.*

YesNo
Student Individual Needs Assessment
What are your plans after high school?*

Attend a 4-year college/universityJoin the militaryAttend a community collegeAttend a trade / technical schoolWork full timeI am not sure of my plans yet
What subjects do you struggle with?*

MathScienceEnglishHistoryForeign LanguageOther
What careers interest you?*
In which of these areas listed do you need assistance? (please check all that apply)*

Academic assistance and advisementCollege awareness and admissions assistanceFinancial aid information and application assistanceCareer awareness and explorationEconomic and financial literacyOther
Participant Confidentiality and Release of School Records

The PipeLine Program of Boys & Girls Clubs of the Tennessee Valley will maintain all student files in a confidential manner. Perti-nent information (i.e. all academic information, report card information or tutorial information) may be shared professionally with Pipe-Line staff members, or the school system child attends. Files for all programs that are grant funded in whole or in part are available for monitoring and subject to audit. Communication of student information to persons or agencies other than those listed above will re-quire express written approval of the student’s parent.

A PipeLine staff representative has explained the above information, regarding the release of information in my students file main-tained by PipeLine of BGCTNV to me. I agree to the release of information to persons or agency as listed above. I understand that any release of information to persons or agencies other than those mentioned above will require my written approval.
Student's Signature *

Clear
Parent/Guardian's Signature*

Clear
I (We) understand that PipeLine will use the data provided on this form to assist in assessing any academic or career planning needs and that all of the information will be used in the strictest of confidence. I certify that all information provided is correct to the best of my knowledge.
Student's Signature*

Clear
Parent/Guardian's Signature*

Clear
Date*
Should be Empty:

Parent/Guardian Information