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Student Information
Student's Full Name
*
First Name
Last Name
Student's Preferred Name
Student's Preferred Pronouns
Student's Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student's Phone Number
Format: (000) 000-0000.
What kind of phone is this?
Please Select
Student's Cell Phone
Parent/Guardian's Cell Phone
Home Phone
Student's Personal Email
example@example.com
Student's School Email
example@example.com
Student's Date of Birth
*
-
Month
-
Day
Year
Date
Student's Sex Assigned at Birth
*
Male
Female
Student's Ethnicity (please pick one):
*
Hispanic/Latino
Non-Hispanic/Latino
Student's Race (please select all that apply):
*
American Indian or Alaskan Native
Asian
Black/African American
Hawaiian/Pacific Islander
White/Caucasian
Is the student a participant in another federal TRIO program?
*
Yes
No
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TRIO Participation
What TRIO program does the student participate in (ex. SLU Upward Bound, Harris Stowe Talent Search, etc.)?
*
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Student Eligibility
Is the student a U.S. citizen?
*
Yes
No
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Student Eligibility Details
Please check the box that best describes the student's circumstance.
*
The student is a permanent resident of the United States;
The student can provide evidence from Immigration & Naturalization Services of their intent to become a permanent resident of the United States;
The student is a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory (Palau); or
The student is a resident of the Freely Associated States.
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School Information
School the Student Currently Attends:
*
Please Select
Confluence Preparatory Academy
Grand Center Arts Academy
Old North Academy
South City Academy
School Counselor's Name
Student's Current Grade
*
Please Select
6th
7th
8th
9th
10th
11th
12th
Student's Expected Year of High School Graduation
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Needs Assessment
Please indicate the areas in which your student would most benefit from support from TRIO Talent Search. Select all that apply.
Academic Skills
*
Test Taking
Study Skills
Note Taking
Time Management
Increasing Current Grades
Tutoring
College & Career Readiness
*
College Visits & Tours
Financial Aid & Scholarships
Goal Setting
ACT/SAT Preparation
Career Exploration
Please rate your student's current skills in each of the following subjects:
*
Rows
Above Average
Average
Below Average
Math
Science
Reading
Writing
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Household Information
How many people* live in the student's household?
*
*Including the student and any parent/guardian(s) listed on this form.
Household's Annual TAXABLE** Income
*
**This information can be found on line 15 of your most recent Form 1040 tax return. We do not report this information at any point.
Is the student a ward of the court, in foster care, or an emancipated minor?
*
Yes
No
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Parent/Guardian 1
Parent/Guardian 1's Full Name
*
First Name
Last Name
Parent/Guardian 1's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1's Email Address
*
example@example.com
What is Parent/Guardian 1's relationship to the student?
*
Natural or Adoptive Parent
Legal Guardian
Temporary Guardian
Other
What is the highest level of education Parent/Guardian 1 has COMPLETED?
*
Less than a high school diploma
High school diploma
Career/vocational/technical school
Associate (2-year) degree
Bachelor's (4-year) degree or higher
Does the student live with and receive more than half of their support from another adult in addition to Parent/Guardian 1?
*
Yes
No
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Parent/Guardian 2
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
What is Parent/Guardian 2's relationship to the student?
*
Natural or Adoptive Parent
Legal Guardian
Temporary Guardian
Other
What is the highest level of education Parent/Guardian 2 has COMPLETED?
*
Less than a high school diploma
High school diploma
Career/vocational/trade school
Associate (2-year) degree
Bachelor's (4-year) degree or higher
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Information Release & Signatures
As a federally funded program, TRIO Talent Search must collect and track academic information including GPA, academic performance, and enrollment in high school and college. This information is collected and stored in accordance with U.S. Department of Education regulations. Your signature below indicates your agreement to the following statement:
I give TRIO Talent Search permission to gather follow-up information about my student's academic progress when appropriate, including, but not limited to, enrollment in and progress at a postsecondary institution utilizing the National Student Clearinghouse for six years after high school graduation.
I hereby certify that, to the best of my knowledge, the information provided on this document is true and accurate.
Student Signature
*
Date
-
Month
-
Day
Year
Date
Parent/Guardian Signature
*
Date
-
Month
-
Day
Year
Date
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