ETS Program Application 2019-2020maui.hawaii.edu/.../05/TS_Middle-School-TRiO-App-2019_20.pdfThe...
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STEP 1 OF 7: 6th - 8th Grade Application Student name: Pronoun preference: ( ) - ( ) - / / Student is a U. S. citizen? YES NO, but student is a permanent resident. Student's Permanent Resident Alien Number is: STEP 5 OF 7: Determination of Dependency Street Address State Apt # City Zip Code L ast Name African American/Black Asian American Caucasian/White Student's birth date: Other: Student's age: A ETS Program Application 2019-2020 Print in Blue or Black Ink Text Opt-Out: Pacific Islander American Samoa Federated States of Micronesia Citizen of? Guam Republic of Marshall Islands NO, student is not a U.S. Citizen, and student is not a permanent resident. Republic of Palau Northern Mariana Islands $ -OR- N ot required to file taxes What is your family’s taxable (not total) income from the last calendar year? (Adjusted Gross Income) If English is NOT the student's first language, do they have a difficult time speaking, reading, or writing English? What is the total number of persons (including you) in your family's household? Hispanic or Latino Native American or Alaskan Native Native Hawaiian STEP 2 OF 7: Citizenship Sex assigned at birth: Yes No No No Male Female Form 1040 Line 10 Yes No No No This institution is an equal opportunity provider. Important Notice: All Applicant information will be kept in strict confidence and not released. Grade: Parent Name: __________________________________________ Parent Phone: __________________________________________ Text Opt-Out Parent Email: __________________________________________ a. b. c. d. e. f. Will this student be 24 years of age before December 31? At any time since the student turned 13, were they an orphan, in foster care, or a ward of the court? Prior to reaching 18 years of age, is the student an emancipated minor or have a court-appointed legal guardian? As of today, is the student married? Does the student have children or dependents (other than spouse) who receive more than half their support from? Is the student homeless (i.e. you lack a fixed, regular, & inadequate nighttime residence) or at risk of becoming homeless? Please complete Steps 6 - 7 and provide applicant signature on the back. Is either parent on active military duty? Does the student have a documented disability? The following questions pertain to the student applicant. If you answer “YES” to any of the questions below, the Income Verification section will be based on your (the student’s) income information. If all responses are “NO”, the Income Verification will be the parent’s information and the application will need to be signed by both the student applicant and the parent and/or guardian. Do either of your parents that you regularly live with and receive support from have a Bachelor's (4-year college) degree? Yes No No No Yes No No No First Name Middle Initial What is student's mailing address? Name of school: Student's home phone number? Student's cell phone number? Student's e-mail address? Student's ethnicity: Yes No No No Yes No No No Yes No No No Yes No No No Yes No No No Yes No No No STEP 3 OF 7: Parent Information STEP 4 OF 7: Income Verification
Transcript of ETS Program Application 2019-2020maui.hawaii.edu/.../05/TS_Middle-School-TRiO-App-2019_20.pdfThe...
STEP 1 OF 7: 6th - 8th Grade Application
Student name:
Pronoun preference:
( ) - ( ) -
/ /
Student is a U. S. citizen? YES NO, but student is a permanent resident.
Student's Permanent Resident Alien Number is:
STEP 5 OF 7: Determination of Dependency
Street Address
State
Apt #
City Zip Code
L ast Name
African American/Black Asian American Caucasian/White
Student's birth date:
Other:
Student's age:
A
ETS Program Application 2019-2020
Print in Blue or Black Ink
Text Opt-Out:
Pacific Islander
American Samoa Federated States of Micronesia
Citizen of? Guam Republic of Marshall Islands
NO, student is not a U.S. Citizen, andstudent is not a permanent resident.
Republic of Palau Northern Mariana Islands
$ -OR- Not required to file taxes
What is your family’s taxable (not total) income from the last calendar year? (Adjusted Gross Income)
If English is NOT the student's first language, do they have a difficult time speaking, reading, or writing English?
What is the total number of persons (including you) in your family's household?
Hispanic or Latino Native American or Alaskan Native Native Hawaiian
STEP 2 OF 7: Citizenship
Sex assigned at birth:
Yes No No No
Male Female
Form 1040 Line 10
Yes NoNoNo
This institution is an equal opportunity provider.Important Notice: All Applicant information will be kept in strict confidence and not released.
Grade:
Parent Name: __________________________________________
Parent Phone: __________________________________________Text Opt-Out
Parent Email: __________________________________________ a.
b.
c.
d.
e.
f.
Will this student be 24 years of age before December 31?
At any time since the student turned 13, were they an orphan, in foster care, or a ward of the court?
Prior to reaching 18 years of age, is the student an emancipated minor or have a court-appointed legal guardian?
As of today, is the student married?
Does the student have children or dependents (other than spouse) who receive more than half their support from?
Is the student homeless (i.e. you lack a fixed, regular, & inadequate nighttime residence) or at risk of becoming homeless?Please complete Steps 6 - 7 and provide applicant signature on the back.
Is either parent on active military duty? Does the student have a documented disability?
The following questions pertain to the student applicant. If you answer “YES” to any of the questions below, the Income Verification section will be based on your (the student’s) income information. If all responses are “NO”, the Income Verification will be the parent’s information and the application will need to be signed by both the student applicant and the parent and/or guardian.
Do either of your parents that you regularly live with and receive support from have a Bachelor's (4-year college) degree?
Yes NoNoNo Yes NoNoNo
First Name
Middle Initial
What is student's mailing address?
Name of school:
Student's home phone number?
Student's cell phone number?
Student's e-mail address?
Student's ethnicity:
Yes NoNoNo
Yes NoNoNo
Yes NoNoNo
Yes NoNoNo
Yes NoNoNo
Yes NoNoNo
STEP 3 OF 7: Parent Information
STEP 4 OF 7: Income Verification
-
This institution is an equal opportunity provider.Important Notice: All Applicant information will be kept in strict confidence and not released.
310 W. Ka'ahumanu Ave. Kahului HI 96732 (808) 984-3286 | Email at [email protected]
3/30/2020
At the end of 8th grade, students will have the chance to opt-out of the ETS program. This will provide students the opportunity to qualify for one of the programs below and all of the benefits that might better suit them during their high school career.
Educational Opportunity Center (EOC), 808-984-3286. GRADE: 12 SERVICES: support through all steps to apply and enroll in post-secondary education (college exploration, college match, financial aid/scholarship application completion, etc.). This program is for seniors and/or students who are primarily interested in several appointments rather than ongoing educational, cultural, and recreational activities. PARTICIPANT EXPECTATIONS: meet with EOC advisor, complete financial aid forms, apply, and enroll in post-secondary education.
Upward Bound (UB)/Upward Bound Math Science (UBMS), 808-984-3299. GRADES: 9-12 SERVICES: promote academic success through tutoring, mentoring, & summer program, career exploration, college information (e.g. affording college, finding and applying to college, applying to scholarships/financial aid), and in-state/mainland college tours. PARTICIPANT EXPECTATIONS: attend monthly Saturday workshops, attend afterschool tutoring if GPA is < 2.5 or D’s/F’s, meet weekly with UB/UBMS advisor at school, participate in a 6-week summer program (academic focus), apply & enroll in college, and maintain contact with UB/UBMS while in college.
PHOTO RELEASE: Unless I select to opt-out, I hereby grant the TRIO program staff and the University of Hawaiˋi Maui College the right to use and publish photographs of me, or in which I may be included, for editorial trade, advertising, and any other purpose and in any manner and medium, and to alter the same without restriction. I hereby release photographer from all claims and liability relating to said photographs (for example, the programs use student photos for brochures or promotional videos).
SCHOOL & COLLEGE RECORD RELEASE: A copy of this final box of the form may be sent to secondary schools and/or colleges for re-lease of transcripts, grades, records, test scores, status of student, and degrees earned. The TRIO programs are required to provide an annual report to the U.S. Department of Education with data obtained from individual student records, which allows for the continuation of funding to offer free student services. As such, we, the undersigned, authorize the release of official and/or unofficial documents reporting grades, test scores, student status, other academic records, and college majors/degrees to TRIO programs at the University of Hawaiˋi Maui College valid from the date below until six years post high school graduation. I understand that the information in these records will only be used to assess the student’s need for program services, evaluate the effectiveness of program activities, and fulfill federal program-reporting requirements. Furthermore, I hereby give the TRIO programs permission to forward my information to other programs and/or department with the University of Hawaiˋi System whose services will best meet my needs.
Student Name (print): ________________________________ Student Signature: _______________________________ Date: ____________
Parent Name (print): _________________________________ Parent Signature: ________________________________ Date: ____________
How can we help you? Please check all the services you may want to use and/or need.
College Awareness & PlanningCultural & Academic Enrichment
At School Tutoring Career Exploration
Study Skills Workshop Financial Aid Planning
Steps 6 OF 7: Needs Assessment
STEP 7 OF 7: Read Below | Sign and Date
Optional OPT OUT if you do not agree for the use of photographs that include you.
Making College Dreams a Reality
