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 Last Name
Your Child's Middle Name
Your Child's School
Ethnicity *
What is your chillds gender? *
Student's Date of Birth *
Age *
What grade is your student in?
Parent/Guardian Name (First & Last)
Cell Phone
Email
Address
Address 2
City
State
Zip
Does your child live with you?
Other Parent/ Guardians Name (if not applicable, leave blank)
Parent/guardian 2: Cell Phone
Parent/Guardian 2: Email
Is your child a US citizen or permanent resident?
Parents' education level: *
Number of people in your household: *

Annual family income (as reported on tax returns)

Please write-in  your family's income AFTER taxes. There are two ways to find this number:

You can calculate this information by taking your monthly take-home pay and multiplying it by 12. 

OR

You can find this information can also located  on your 2021 tax return 1040 form on line 15.
Please indicate your family's income level AFTER taxes: *
If your family receives additional support, please select all that apply: 
TANF/ SNAP benefits
Veteran's benefits
Unemployment Benefits
Social Security Benefits

Release of Records/Certification and  Authorization 

Release of School Records

I hereby authorize Pierce College Legacy Scholars to obtain student transcripts, grades, test scores, attendance, class progress reports, free reduced lunch eligibility, and other forms of documentation from Franklin Pierce High School as long as my son/daughter participates in the program. These records will be used to assess student needs, monitor student program, document program eligibility, and report data required by US Department of Education. All information will be kept confidential. 

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

Permission for Field Trip Participation

I hereby give my child (if selected) permission to participate in all Legacy Scholars Activities, tutoring, field trips, educational/cultural events, and six-week summer college prep academy at Pierce College. Also, I understand 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, as long as reasonable precautions are taken to ensure the safety of my child.
I agree to the Permission for Field Trip Participation statement above (please initial) *

Photo Authorization 

I hereby authorize the Pierce College Talent Search 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)

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. 
*
Please select a signature verification type.