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2 PLEASE SAVE THIS PAGE FOR YOUR RECORDS Dear Applicant and Family: Congratulations on your dedication to your education and your interest in our program! (ETS) is a federally funded TRIO program that is designed to prepare and motivate low income, first generation, or students in need of program services for success in college. We are passionate about guiding students and their families through the college and financial aid process. Students accepted into the program are participants until they graduate from high school. All program services are free, but we expect students to make a serious commitment to both their academic education and the ETS program. All information provided on this application is confidential and kept in a secure location. Please complete the application using a blue or black ink pen. Do not complete the application in pencil. Please submit the completed application to your Advising Coordinator or School Counselor. Incomplete applications will not be reviewed and will delay program services. If you have questions or need assistance filling out the application, please call the office at (626) or us at talentsearch@pasadena.edu. Estimado Solicitante y familia: Felicitaciones por su dedicación a su educación y su interés en nuestro programa! (ETS) es un programa federal que está diseñado para preparar y motivar a los estudiantes de bajos ingresos y / o de primera generación para el éxito en la universidad. Somos apasionados a guiar a los estudiantes y sus familias paso a paso con las aplicaciones universitarias y la aplicación de ayuda financiera. Los estudiantes aceptados en el programa de (ETS) participaran hasta que se gradúen de la escuela secundaria. Todos los servicios del programa son gratuitos, pero esperamos que los estudiantes hagan un compromiso serio tanto a su formación académica y al programa de ETS. Toda la información prevista en esta solicitud es confidencial y se guardará en un lugar seguro. Por favor, complete la aplicación usando una pluma de tinta azul o negro. No complete la solicitud con lápiz. Por favor, envíe la solicitud completa a su Coordinador de Asesoramiento o consejero escolar. Las solicitudes incompletas no serán revisadas y demorará los servicios del programa. Si usted tiene preguntas o necesita ayuda llenar la aplicación, por favor llame a la oficina de Talent Search (626) o envíenos un a talentsearch@pasadena.edu. Please submit the completed application to/ Por favor envié la solicitud complete a: Pasadena City College Building D108
3 Section 1 Student Information Legal Name: (Last) (First) (MI) Home Address: CA (City) (State) (Zip Code) Home Phone: ( ) Student Cell Phone:( ) Sex: Male Female Birthdate: / / Address: School: Grade: Student ID: Expected Graduation Year: Are you currently enrolled in any of the programs listed below: AVID Puente Upward Bound (if yes, which one?) Other Not enrolled in any of these programs Names of siblings currently in : How did you hear about? List any brothers/sisters in grades 8 12 currently attending a Talent Search school. Name School Grade Name School Grade Section 2 Parent/Guardian Information Mother/Guardian name: Home Phone: Work Phone: ( ) Cell Phone: ( ) Father/Guardian name: Home Phone: Work Phone: ( ) Cell Phone: ( ) For Office Use Only Elig: LI & FG LI FG Other Entry G.P.A.: MS /HS. Grad Year: 201 Enter Date / / Initials: Admittance: Approved Wait list Denied Reason: Approval: Project Director Date / / Rev. 9/13
4 Sección 1 Información del Estudiante Nombre Legal: (Apellido) (Primero) (I) Domicilio: CA (Ciudad) (Estado) (Código Postal)) N o de Teléfono: ( ) Celular del Estudiante: ( ) Sexo: M F Fecha de Nacimiento: / / Correo Electrónico: Escuela: Grado: # De ID: Año esperado de graduación: Está inscrito en cualquiera de los siguientes programas?: AVID Puente Upward Bound (si es así cuál? ) Otro No inscrito en cualquiera de estos programas Nombres de hermano/a(s) inscritos en : Cómo se enteró acerca del programa? Indique cualquier hermano o/y hermana en los grados 8 12 que actualmente asisten a una escuela de Talent Search. Nombre Escuela Grado Nombre Escuela Grado Sección 2 Información de la Familia Nombre de Madre/Guardián: Teléfono de la casa: ( ) Teléfono del trabajo: ( ) Teléfono celular: ( ) Correo electrónico: Nombre de Padre/Guardián: Teléfono de la casa: ( ) Teléfono del trabajo: ( ) Teléfono celular: ( ) Correo electrónico: Para uso de oficina solamente Elig: LI & FG LI FG Other Entry G.P.A.: MS /HS. Grad Year: 201 Enter Date / / Initials: Admittance: Approved Wait list Denied Reason: Approval: Project Director Date / / Rev. 9/13
5 Section 3 Eligibility Criteria All information must be complete to be eligible for ETS services. Directions The following section must be completed by the parent/legal guardian. The purpose of this section is to determine program eligibility. Talent Search is required to verify that our participants meet federal guidelines based on educational background and household income level. Applicant Citizenship Status: US Citizen Applicant Social Security # (Required) Permanent Resident: Alien Registration # A First Generation Status (Parents or Guardians educational level): Mother/Guardian Please indicate the highest level of education completed: Less than High School High School Diploma/GED Two year college Four year college Do you have a bachelor s degree from a university/college? No Yes If yes, please indicate college/university name: Degree name: Father/Guardian Please indicate the highest level of education completed: Less than High School High School Diploma/GED Two year college Four year college Do you have a bachelor s degree from a university/college? No Yes If yes, please indicate college/university name: Degree name: Income Status: What is the household s TAXABLE income (this is the amount after all deductions, and is not the gross income) from your most recent filing? (IRS 1040 line 43, IRS 1040A line 27, IRS 1040EZ line 6)? Number of family members living in your household supported by this income? If you did not file taxes, please indicate your total annual income $ Source: Ethnicity: 1. Is your son or daughter Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race)? Yes No 2. Select one or more of the following groups in which you consider the applicant to be a member: (Do not check if not applicable) American Indian or Alaska Native Asian Black/African American White Hawaiian/Pacific Islander Does the applicant live in a foster home or is he/she a ward of the court? Yes No I certify the information provided above is true and correct to the best of my knowledge. I understand that all information shared with TRIO Talent Search and Pasadena City College is strictly confidential. Parent or Legal Guardian Name (please print) Parent or Legal Guardian Signature Date
6 Sección 3 Pasadena City College Criterios de elegibilidad Toda la información debe ser completaba para ser elegible Instrucciones La siguiente sección debe ser completada por el padre / tutor legal. El propósito de esta sección es para determinar la elegibilidad del programa. Talent Search está obligado a verificar que los participantes cumplen con las directrices federales basadas en nivel educativo y el nivel de ingresos del hogar. Estado de ciudadanía: Ciudadano de EE.UU. # De Seguro Social del Estudiante (Requerido) Residente Permanente: Registro de Extranjero # A Estado de primera generación (Nivel educativo de los padres o tutores): Madre/Guardián Por favor, indique el nivel más alto de educación completado: Menos de escuela secundaria Diploma de escuela secundaria/ged Colegio de dos años Colegio de cuatro años Tiene un título de licenciatura de una universidad / universidad? No Si En caso afirmativo, por favor indique nombre de colegio / universidad: Nombre de Titulo: Padre/Guardián Por favor, indique el nivel más alto de educación completado: Menos de escuela secundaria Diploma de escuela secundaria/ged Colegio de dos años Colegio de cuatro años Tiene un título de licenciatura de una universidad / universidad? No Si En caso afirmativo, por favor indique nombre de colegio / universidad: Nombre de Titulo: Estado de Ingresos: Cuáles son los ingresos imponibles del hogar (esta es la cantidad después de todas las deducciones) de su declaración de impuestos más reciente? (1040 del IRS línea 43, 1040A del IRS línea 27,1040 EZ del IRS 1040EZ línea 6)? Número de miembros de la familia que viven en su hogar con el apoyo de estos ingresos: Si no declara sus impuestos, por favor indique sus ingresos anuales totales: S Origen: Etnicidad: 1 Es su hijo o hija hispánico o Latino (Una persona de origen mexicano, puertorriqueño, cubano, centroamericano o sudamericano o de otra cultura u origen español, sin importar la raza)? Si No 2. Seleccione uno o más de los siguientes grupos en los que usted considera que el solicitante es un miembro de: (No marque si no es aplicable) Indio Americano o Nativo de Alaska Asiático Negro / Afro Americano Blanco Hawaiano / Islas del Pacífico Tiene el solicitante vive en un hogar de crianza o está él / ella bajo la tutela de la corte? Si No Al firmar esta solicitud certifico que todo lo antes dicho es verdadero y esta solicitud fue llenada con mi mejor intención y capacidad. Entiendo que la información proporcionada a TRIO Talent Search y a Pasadena City College es confidencial. Nombre del padre/ Guardián (con letra de molde) Firma del padre/ Guardián Fecha
7 School Name Student Name (Print Clearly) Grade: Section 4 Parent/Guardian Authorization By signing below, I/we authorize and certify the following 1) All of the information I have provided on this application is accurate and correct. 2) TRIO is granted access to my student s school transcripts, progress report, standardized test scores, SAT/ACT scores, free/reduced lunch records and any other information which is necessary for participation of the student in the program. 3) TRIO is granted permission to verify postsecondary enrollment, retention, and completion information. 4) TRIO may use my student s picture for promotional and/or educational use in program publication materials (brochures, flyers, website, and displays). 5) TRIO is granted access to student s financial aid information from colleges and the federal government to provide necessary advisement on financial aid eligibility and options. 6) We, the parents/guardian of above stated student agrees to encourage our son/daughter to attend college immediately following high school graduation. Parent/Guardian Name (Print Clearly): Parent/Guardian Signature: Date: Section 5 Student Needs Assessment What do you need assistance with to prepare for college? Academic Tutoring after school tutoring and referral to tutorial services. Academic Planning middle and/or high school graduation requirements, A G college admission requirements (rigorous curriculum courses). Pre College Advisement benefits of a college education, college admission requirements, research college/university options, visit various colleges/universities, assistance completing community college, CSU, UC, Private, and out of state applications. Financial Aid Advisement information on federal aid programs, assistance completing the Free Application for Federal Student Aid (FAFSA) and scholarship research. Financial and Economic Literacy information on budgeting, savings, credit and debt. Career Exploration research careers, visit job sites, and tour colleges. Study Skills test taking strategies, time management, and note taking skills Life Skills goal setting, conflict resolution, self esteem. Visit College Campuses & Cultural Enrichment Exposure to colleges/universities and cultural events (e.g. theater, museum tours) Computer Technology computer use and assistance, internet use and safety, online college and scholarship research, supplemental learning software available. Mentor program receive individual and small group advisement on educational and career options. What careers are you interested in? What college(s) are you interested in? I don t know I don t know
8 Escuela Nombre del Estudiante (Escriba Claramente) Grado: Sección 4 Autorización del padre guardián Al firmar abajo, yo/nosotros autorizamos las siguientes 1) Toda la información que he proveído en esta solicitud es exacta y correcta. 2) El programa de TRIO se le concede acceso a los expedientes de la escuela de mi estudiante, resultados de exámenes estandarizados, SAT / ACT, y cualquier otra información que sea necesaria para la participación del estudiante en el programa de ETS. 3) TRIO puede usar la imagen de mi hijo en publicaciones de materiales (folletos, páginas web y boletines). 4) Doy mi permiso al acceso de información a la inscripción en la universidad, la retención, y graduación del estudiante. 5) Doy mi permiso al acceso a información sobre ayuda financiera de las universidades y el gobierno federal. 6) Nosotros, los padres / tutores de el estudiante antes mencionado nos comprometemos a animar a nuestro hijo / hija a asistir a la universidad inmediatamente después de graduarse de la secundaria. Nombre del padre/guardián (Escriba Claramente): Firma del padre/guardián: Fecha: En qué necesita asistencia para prepararse para la universidad? Marque todas las que apliquen Tutoría Académica tutoría después de escuela y referencias a servicios tutoriales. Planificación Académica requisitos de graduación de la escuela intermedia y secundaria, requisitos de admisión universitaria (cursos rigurosos). Consejería Universitaria beneficios de tener una educación universitaria, los requisitos de admisión universitaria, la investigación universitaria/opciones de universidades/colegios, visitas a varios colegios, ayuda para aplicar al colegio comunitario, CSU, UC, privado y colegios fuera del estado. Asesoría de Ayuda Financiera información sobre los programas federales de ayuda económica, asistencia para completar la Solicitud de Ayuda Federal (FAFSA) e investigación de becas escolares. Educación Financiera información sobre presupuestos, ahorro, crédito, y deuda. Exploración de Carreras investigación de carreras, visitas a sitios de trabajo. Técnicas de Estudio estrategias para tomar examines, manejo del tiempo, técnicas para tomar notas. Técnicas de la Vida establecimiento de metas, resolución de conflictos, autoestima. Visitas a Colegios y Culturales exposición a colegios/universidades y eventos culturales(teatro, museos). Tecnología asistencia con el uso de computadora, Internet y la seguridad. Programa de Mentores recibir asesoría individual y en grupos pequeños sobre las opciones educativas. En qué carreras está interesado en este momento? No sé En qué universidades está interesado en este momento? No sé
--PLEASE SAVE THIS PAGE FOR YOUR RECORDS--
Dear Applicant and Family: --PLEASE SAVE THIS PAGE FOR YOUR RECORDS-- Congratulations on your dedication to your education and your interest in our program! (ETS) is a federally funded TRIO program that
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