Empower-ED Academy Application
Please note: We MUST ask for student & parent information from each applicant because our programs are funded by the Grants and Foundations. We MUST collect certain information to ensure student eligibility and stay in compliance with federal law. Your information will NOT be used for anything other than eligibility and government reporting purposes. Please type in the box below "ACCEPT" and proceed to the next section.
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Part I: Student Applicant Information
Name
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First Name
Last Name
Student Date of Birth
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MM/DD/YYYY
Student Age
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Student Social Security Number
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Citizenship
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Please Select
U.S. Citizen
Permanent Resident
Other
Gender
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Female
Male
Nonbinary
Other
What Is Your Ethnicity?
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Hipanic
Asian
Native Hawaiian or other Pacific Islander
White
American Indian/Alaskan Native
Other
Personal Phone Number
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Please enter a valid phone number.
Student Personal Email Address (Not Your School Email)
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Residential Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What School/Colleges do you currently attend?
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School Student ID Number
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What is your current grade level?
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What is your GPA? (It is okay if you do not know)
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Expected High School Graduation Year
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Who do you live with?
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Please Select
Mother & Father
Mother
Father
Guardian
Other
What language is spoken at home?
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Are you currently being served by another TRIO program, such as Talent Search?
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Please Select
Yes
No
Unsure
Why do you want to participate in Empower-Ed?
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Write a MINIMUM of 2-3 sentences (REQUIRED)
How do you think you will benefit from the experience?
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Write a MINIMUM of 2-3 sentences (REQUIRED)
How do you think the program will prepare you for post-secondary education?
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Write a MINIMUM of 2-3 sentences (REQUIRED)
Part II: Parent Guardian Information
Parent/Guardian #1
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First Name
Last Name
Relationship to Student
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Ex: Mother, Father, Grandmother, Grandfather, Brother, Aunt, Uncle...etc
Parent/Guardian Phone Number
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Please enter a valid phone number.
Parent/Guardian Email
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example@example.com
Residential Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Highest Level of Education Obtained
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Please Select
High School Diploma/GED
Technical/Occupational Certification
Associate Degree
Bachelor's Degree
Graduate School
Unknown
Parent/Guardian #2
First Name
Last Name
Relationship to Student #2
Ex: Mother, Father, Grandmother, Grandfather, Brother, Aunt, Uncle...etc
Parent/Guardian Phone Number #2
Please enter a valid phone number.
Parent/Guardian Email #2
example@example.com
Residential Address #2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Highest Level of Education Obtained #2
Please Select
High School Diploma/GED
Technical/Occupational Certification
Associate Degree
Bachelor's Degree
Graduate School
Unknown
Part III: Family Income Information
Number of people living in your household
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Household Income Rate
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Please Select
$0-$21,870
$21,871-$29,580
$29,581-$37,290
$37,291-$45,000
$45,001-$52,710
$52,711-$60,420
$60,421-$68,130
$68,131-$75,840
$75,841+
Please provide a copy of your most recent 1040 Form
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Two Documents Required: Note: Your application will not be considered applicable if these documents are not turned in
Email hieu.le@empowered918.onmicrosoft.com a copy of your School Transcript and a Counselor's Recommendation Letter.
Part IV: Signatures
Student Signature
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Parent Guardian Signature
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I certify that the information provided on this form is true and complete to the best of my knowledge.
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