Participant Application Step 1 of 5 0% STEP 1 – STUDENT INFORMATIONStudent Name* First Middle Last Student Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Cell Phone Number*Will be used to provide information about upcoming events. If the student does not have a cell phone number, please enter “(000) 000-0000”. Please do not enter a parent number in this section, this can be entered in the “Parent Information” section.Can we text you about upcoming events/important information?*-Select One-YesNoN/AStudent Email Address (please list an email you check frequently)* Enter Email Confirm Email What is the student's Race/Ethnicity?* American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Please select all that apply.Student Gender*-Select One-MaleFemaleStudent Citizenship Status*-Select One-U.S. CitizenU.S. Permanent ResidentNone of the aboveSchool InformationSchool*-Select One-Hidden Valley Middle SchoolMission Middle SchoolDel Dios Academy of Arts & SciencesOrange Glen High SchoolEscondido High SchoolSan Pasqual High SchoolDel Lago AcademyRancho Minerva Middle SchoolVista Innovation & Design AcademyVista High SchoolRancho Buena Vista High SchoolGrade Level*-Select One-6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeStudent ID Number Leave blank if you don’t know it. We can find this later.Current GPA* Is the student currently a participant in any of the programs below?* Palomar College Upward Bound Cal State San Marcos Upward Bound Wahupa ETS AVID None of the above STEP 2 – PARENT/GUARDIAN INFORMATIONParent/Guardian 1 (Required)* First Last Relationship to Student*-Select One-MotherFatherStep-ParentOther RelativeLegal GuardianParent/Guardian 1 Cell Phone Number*Can we text you about upcoming events/important information?*-Select One-YesNoParent/Guardian 1 Email Address (please list an email you check frequently)* Parent/Guardian 2 (Optional) First Last Relationship to Student-Select One-MotherFatherStep-ParentOther RelativeLegal GuardianParent/Guardian 2 Phone NumberCan we text you about upcoming events/important information?-Select One-YesNoParent/Guardian 2 Email Address (please list an email you check frequently) STEP 3 – ELIGIBILITY INFORMATIONParent Education LevelHas the student's mother received a bachelor's degree (BA) or higher that was awarded in the United States?*-Select One-YesNoUnknownHas the student's father received a bachelor's degree (BA) or higher that was awarded in the United States?*-Select One-YesNoUnknownWith who does the student regularly reside with and receives support from?*-Select One-Both Mother and FatherMother OnlyFather OnlyOther Relative/GuardianHousehold Income InformationWhat is the total number of persons that live in the household? (including the student)*-Select One-23456789101112Please select the statement that best applies to you:*-Select One-I filed my taxes, I will enter my taxable yearly income below.I did not file my taxes, I will enter my approximate taxable yearly income below.I will file my taxes, I will enter my approximate taxable yearly income below.My family had no taxable income during the last calendar year (Please enter "0" below).Total taxable income from the last calendar year:*Please enter a number from 0 to 1000000. STEP 4 – EMERGENCY CONTACT INFORMATIONThis should be individuals other than the student’s parent/guardians who can be contacted if there is ever the need and the parent/guardian cannot be reached.Emergency Contact #1 (Required)* First Last Relationship to Student* Phone/Cell Number*Emergency Contact #2 (Optional) First Last Relationship to Student Phone/Cell Number STEP 5 – CONSENT AND SUBMITConsent*By signing this application, I attest that all the information on this application is true and accurate to the best of my knowledge. Moreover, I authorize the release of the student’s official academic records to the Grant Funded Student Programs (GFSP) at Palomar College, understanding that the information in these records will be used only to assess the student’s need for TRIO program services, discern the student’s educational progress, evaluate the effectiveness of TRIO program activities, and fulfill TRIO program-reporting requirements. Additionally, I authorize GFSP to use the student’s name, statements and likeness, without charge, for promotional purposes in GFSP publications, advertising, video, and other formats. Finally, my child and I agree to indemnify, save, and hold harmless and release and forever discharge Palomar College and their employees and agents by reason of acts, illness, injury or other consequences arising out of or resulting directly or indirectly from my child’s participation in the aforementioned program, or any time subsequent thereto. I hereby give consent to Palomar College and their employees and agents to render medical treatment and assistance to my child if the rendering of such treatment should become necessary or desirable during the course of the program. I agree to the statement above.Parent/Guardian Signature*Date* MM slash DD slash YYYY Δ
