Pierce College Legacy Scholars Application

Your child is interested in joining the Pierce College Legacy Scholars, a federally funded program that encourages students to graduate from high school and enroll in college.

This free program support students through individual and group sessions throughout the year. The program provides workshops focused on success in high school, career awareness, college selection and financial assistance. In addition, we have special events including college visits and summer programming to give opportunities for students to gain leadership skills, learn more about careers and visit college campuses.

Please fill out the application below. The information we collect is required from the Federal Government to ensure your child's eligibility. All information is kept confidential.

Your Child's First Name *

Preferred Name

Your Child's Middle Name

Your Child's Last Name *

Your Child's School *

What grade is your student in? *

Student's Date of Birth *

Age *

What is your chillds gender? *

Is your child a US citizen or permanent resident? *

Ethnicity *

Parent/Guardian Name (First & Last) *

Cell Phone *

Email *

Address *

City *

State *

Zip *

Does your child live with you? *

Do you have a 4- year college degree? *

Other Parent/ Guardians Name (if not applicable, leave blank)

Parent/guardian 2: Cell Phone

Parent/Guardian 2: Email

Does your student live with this Parent/Guardian?

Does this parent have a 4- year degree (a Bachelors Degree)

Income Eligibility

To be eligible for Legacy Scholars, a parents/guardians income after taxes must fall into one of the categories listed in the drop-down menu below.

To estimate your income after taxes, please take your monthly take-home pay and multiple it by 12.

Please indicate your family size/ income level: *

Please note: We are required to notify applicants of all the ways they can verify their income. If you chose to, you can also confirm your income level by uploading your 1040 tax form or any other state benefit documentation that includes your income information. This is optional.

Upload any optional documents here (not required):

Release of Records / Certification & Authorization

Release of School Records

I hereby authorize the Pierce Upward Bound program to obtain student transcripts, grades, test scores, attendance, class progress reports, free reduced lunch eligibility, immunizations, etc. from Clover Park School District if my child participates in the program. I also authorize the Pierce Upward Bound program to release such records to other institutions as they relate to my child’s educational program. These records will be used to assess student needs, monitor student progress, document program eligibility, and report data required by the US Department of Education. All information will be kept strictly confidential.

I agree to the Release of School Records above (please initial) *

Photo Authorization

I hereby authorize the Pierce College Upward Bound to use photographs of my child in its public education materials and news releases. I understand these photographs will not be sold or used for commercial purposes. (Optional)

I agree to the Photo Authorization Statement above (Please initial) *

Permission for Field Trip Participation

I hereby give my child (if selected) permission to participate in all Pierce College Legacy Scholars activities, tutoring, field trips, and educational/cultural events. Also, I understand that this opportunity to participate involves normal risks and I am willing to assume the risks and hazards to such participation. I agree to hold Pierce College Legacy Scholars harmless for any accident that may occur, if reasonable precautions are taken to ensure the safety of my child.

I agree to the Permission for Field Trip Participation statement above (please initial) *

Grievance Procedure

In line with Pierce College Talent Search Codes of Conduct, you have the right to be treated with respect at all times. Pierce College Talent Search staff is to exhibit the highest standard of personal and professional behavior while performing their job duties. If you feel your rights have been violated you are dissatisfied or have complaints with the program the following steps are to be taken for resolution:

1. Talk to the person you have a concern about

2. If satisfaction is not achieved, talk with the Talent Search Directors

3. If satisfaction is not achieved, talk with the Talent Search Director's Supervisor.

I have read and understand the above grievance procedure to be followed if I feel that my rights have been violated.

I agree to the Grievance Procedure Statement above (Please initial) *

My signature below indicates that to the best of my knowledge the information provided on this application is true, complete and accurate.

To sign this document, you must select one of the methods below to verify your signature.