college of southern nevada - csn...field trip to southern utah university in cedar city, utah and...

College of Southern Nevada

TRiO 2017 Summer Bridge Program Application Checklist

_____ Read the TRiO Summer Bridge ‘Frequently Asked Questions’

_____ Complete and sign the TRiO SSS Application (Front and Back)

_____Provide a copy of your family’s SIGNED 2016 Income Tax

_____ Complete the ‘Application Survey’

_____ Complete the ‘College Readiness Survey’

_____ Read and sign the ‘Program Release of Information’ and ‘Program Photo/Media Release’

_____ Read and sign the “TRiO Summer Bridge Agreement and Commitment” (See below)

Applications will be accepted until June 12, 2017 (or the Summer Bridge Program is filled).

TRiO Summer Bridge Agreement and Commitment

The College of Southern Nevada TRiO SSS allows admitted first-year students to get a head start on their CSN

education. During this FREE two-week program, students attend various TRiO workshops, Writing and Reading

Comprehension Strategies, Math Preparatory Skills Workshops, College Preparatory Presentations and other

activities to help provide for a smooth transition to CSN in the fall.

I, , make a commitment to attend the TWO week CSN TRiO Summer

Bridge from June 19 – June 30, 2017 at North Las Vegas Campus.

(Please initial the following) I understand that I am committing to attend ALL sessions from 8:30AM – 12:30PM for two weeks.

_____ I understand that the final day of the program, June 30, 2017 will be a full day commitment for a scheduled

field trip to Southern Utah University in Cedar City, Utah and Dixie State College in St. George, Utah.

I will provide my own transportation to and from the North Las Vegas Campus.

I may not be absent for activities such as work, family vacations, etc. while attending the TRiO Summer

Bridge

I will have the opportunity to participate in the academic year component of TRiO SSS starting in Fall 2017

while enrolled at CSN.

By signing this letter I commit to ACTIVELY PARTICIPATE in the TRiO Summer Bridge Program.

Student Name (Print) Signature Date

TRiO SSS, North Las Vegas Campus, 3200 E. Cheyenne Ave, N. Las Vegas, NV 89030, (702) 651-4441 tel, (702) 651-4527 fax

TRiO SSS, Cheyenne Campus, 3200 E. Cheyenne Ave, N. Las Vegas, NV 89030, (702) 651-4441 tel, (702) 651-4527 fax

TRiO Summer Bridge College of Southern Nevada, Cheyenne Campus

Frequently Asked Questions

What is TRiO Student Support Services (SSS)? The College of Southern Nevada (CSN) TRiO Student Support Services (SSS) started in 2001 and is funded by the U.S. Department of Education. CSN TRiO SSS annually provides individual and group services to 200 students so that they develop the skills and motivation necessary to achieve an associate’s degree. What is the TRiO - Student Support Services (SSS) Summer Bridge Program? CSN TRiO SSS allows admitted first-year students to get a head start on their CSN education. During this two-week program, students experience various TRiO workshops, Writing and Reading Comprehension Strategies, Math Preparatory Skills Workshops, College Preparatory Presentations and other activities to help provide for a smooth transition to CSN. Summer Bridge participants will also have the opportunity to participate in the academic year component of TRiO SSS while enrolled at CSN Who is eligible for TRiO - SSS Summer Bridge? CSN TRiO SSS participants must be U.S. citizens or permanent residents pursuing their associate’s degree. Program participants must demonstrate academic need for services and meet at least one of the following criteria:

Low-income student: a student whose family meets federal income eligibility guidelines and has financial need

First generation college student: a student where neither custodial parent/guardian has graduated from a four-year institution at the time of the student’s enrollment in the TRiO SSS program (MUST provide copy of signed recent Tax Income of Family)

College student with documented disabilities, as verified by CSN Disability Resource Center (DRC).

***Students must also have a commitment to their college success.***

How much does it cost to participate in TRiO - SSS Summer Bridge? There are no out-of-pocket costs for Summer Bridge. Covered costs include summer workshops, supplies, lunch, snacks, and activity fees. Students may want to bring money for miscellaneous personal expenses not covered by the program.

What are dates and time for the TRiO SSS Summer Bridge 2017 TRiO SSS Summer Bridge is from June 19th – June 30th, 8:30AM – 12:30PM. And on Friday June 30th, the program will take an all day trip to Cedar City and St. George Utah to tour Southern Utah University and Dixie State University. How do I get to campus during TRiO SSS Summer Bridge? All participants are expected to provide their own transportation to and from CSN North Las Vegas Campus during the program.

TRiO SSS, Cheyenne Campus, 3200 E. Cheyenne Ave, N. Las Vegas, NV 89030, (702) 651-4441 tel, (702) 651-4527 fax

How much does it cost for parking? Parking is FREE. However, CSN TRiO SSS assume no responsibility or payment for violations, damage to, or loss from personal vehicles.

May I work or have other outside commitments during TRiO SSS Summer Bridge? The TRiO SSS Summer Bridge schedule is rigorous and demanding; we meet daily and attendance is required at all program activities. Students may not be absent for activities such as work, family vacations, etc. Please keep this in mind before deciding to apply for Summer Bridge. Students are expected to commit fully to TRiO SSS Summer Bridge during the two-week program.

What are some other reasons I should apply to, and participate in, TRiO SSS Summer Bridge? Besides the head start on your college career:

You’ll make friendships with other new CSN students before the academic year begins You’ll have a network of faculty, staff, and peers in a supportive learning environment You’ll enhance your study skills in college-level reading, writing, critical thinking, and

public speaking You’ll participate in academic seminars, workshops, and other on and off campus

activities designed to familiarize you with CSN and your North Las Vegas community It’s a once in a lifetime opportunity

Great! What is the application process?

1. Be admitted to College of Southern Nevada (CSN) 2. Complete a CSN TRiO SSS and Summer Bridge application, either:

o Obtain from the TRiO SSS office, or o Sent to you via e-mail

3. Complete the Free Application for Federal Student Aid (FAFSA) 4. Take the CSN Placement test for Math and English

How will I know if I have been admitted to Summer Bridge? Keep an eye out for your “Welcome to Summer Bridge” information packet via e-mail. Information on meeting location, pertinent information, etc. will be sent to you. It will be a great idea to keep your phone number current as well. Again, please call 651-4441 if there is any change to your contact information.

TRiO Student Support Services 2017 SUMMER BRIDGE Application Checklist

Completed?

Yes No Comments

Application Completed? (black or blue ink only)

Make sure ALL areas of application are complete in black or blue ink;

personal information, dates, signatures, e-mail PRIOR to the

appointment.

Unofficial Transcript High School

Social Security Card? Must bring Social Security Card

(to be copied in TRIO Office)

Financial Information

Yes No Comments

Tax Return ( Copy of parents’ signed 1040, 1040a or 1040EZ or Puerto Rico tax return)

Make sure the second page is signed.

If no tax return was filed, verification from a government source

Example: Social Security Award Letter, Food Stamps, etc.

***Meeting First Generation, Low Income, and Disability program eligibility criteria does not guarantee admission into the TRIO Student Support Services program. Prospective participants MUST ALSO demonstrate the ability to benefit from the program services***

TRiO SUMMER BRIDGE PROGRAM APPLICATION All information is CONFIDENTIAL.

OFFICE USE ONLY

ELIGIBILITY □ LIFG □ LI □ FG □ DI □ DILI INTERVIEW DATE:________________________

SUMMER BRIDGE ADMISSION STATUS: _____ADMITTED _____DENIED _____WAITING LIST REASON__________________ Documents: _______ ADMISSION TO CSN _______FA INFO ______ PLACEMENT SCORES

Recommending Staff’s Signature ___________________________________________ Date:_____________________

Director’s Signature ______________________________________________________ Date: ____________________

PERSONAL INFORMATION (PLEASE PRINT CLEARLY) NSHE # ________________________________

Name___________________________________________Social Security # __________________________

Last First MI

Address_______________________________________ Home Phone# ____________________________ Street Apt. Area Code

_______________________________________ Cell Phone # _____________________________ City State Zip Area Code

EMAIL ADDRESS (required): __________________________________________________________________________________

Are you a U.S. Citizen? □ Yes □ No, Permanent Resident, Alien Number A-_________________ (copy of Alien Card required)

Ethnicity / Race Are you Hispanic/Latino? □ Yes □ No Please select the category or categories with which you most closely identify: □ White □ Black/African-American □ American-Indian or Alaska Native □ Asian □ Native Hawaiian/Pacific Islander

Gender □ Female □ Male Date of Birth ________/________/_______ MM DD YEAR Permanent Contact ___________________________________________/___________________________ Name Relationship

Address:_________________________________________ Permanent Phone# _______________________ Street City/State Zip Area Code

How did you find out about TRIO?_____________________________________________________________

ELIGIBILITY CRITERIA:

INCOME (TRiO Staff will help determine this. Please bring a copy of recent family tax return) Dependent student: Parent/family’s latest annual taxable income_________ Number of dependents in family_______

Independent student: Your latest annual taxable income ________________ Number of dependents in family_______

Have you applied for financial aid?

□ Yes – If yes, provide documentation from the Financial Aid Office. Receiving PELL Grant? □Yes □ No

□ No – If no, we encourage you to apply on-line at www.fafsa.gov or in person at the CSN Financial Aid Office.

FIRST GENERATION

Did either one of your parents earn a degree from a four-year college? □ Yes □ No

DISABILITY [Must bring documentation from DRC]

Do you have a physical disability? □ No □ Yes, Type ________________________________________

Do you have a learning disability? □ No □ Yes, Type________________________________________ I CERTIFY THAT ALL INFORMATION PROVIDED ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I GIVE STUDENT SUPPORT SERVICES STAFF PERMISSION TO OBTAIN MY RECORDS FOR VERIFICATION AND SERVICE PRESCRIPTION PURPOSES.

Applicant Signature _________________________________________________ Date: _____/_____/_____ MM DD YEAR

http://www.fafsa.gov/

STUDENT NEEDS ASSESSMENT

Previous Education High School Graduation Year _________________ or GED Year _______________________ College Major ______________________________Year and Semester started at CSN__________

Current Semester Units ____________ College credits earned so far _________________________

College Location (circle one): North Las Vegas West Charleston Henderson

Your educational goal (check all that apply):

□ Certificate □ Associate’s Degree

□ Transfer to a four-year school

□ Associate’s Degree and then Transfer

Main reason why you are applying to the TRIO Student Support Services Program ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ State your educational and professional goals ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What different challenges do you face while attending CSN?

□ Disability □ Limited English □ Financial Issues

□ Motivation □ Transportation □ Lack of study skills

□ Health Problems □ Child Care □ Family Problems

□ Other____________________________________________________________

PLEASE PLACE A CHECK NEXT TO ALL SERVICES THAT APPLY:

□ Personal counseling & college adjustment issues □ Transfer counseling

□ Academic advising □ Study & college survival skills development

□ Choosing a major □ Class scheduling/registration

□ Computer lab □ Career counseling

□ Financial aid & scholarship assistance

□ Special instruction (reading, writing, math, computers)

Revised: 2/28/2017

1. What subject(s) do you feel that you do your best in? Why? (Be specific, for example English because I like to read, or Math because I am good with numbers).

2. What subject(s) do you feel that you do your worst in? Why? (Be specific, problems with language, adding, vocabulary etc.)

4. What is the single most important reason affecting your performance in tests and in grades in general? (For example, if it’s time commitment because you are a parent, being tired from working all day, problems with Math or English skills etc.) (The more detail you provide us, the more we might be able to do for you).

3. In the subjects that you do your worst in, would you say you…? (Mark all that apply).

o Study less than you should

o Avoid studying the subject because it makes you anxious

o Try just as hard as the ones you do the best

o Try to go over your notes right after class to see if your understanding improves

o Wait until the night before the test to study the notes

o Try to get a good amount of sleep before taking the test

o Feel unprepared because you believe you do not have the basic skills (reading, writing or math) to do well

o Do you ask the teacher for help, or ever seek assistance from a counselor? If not, why?

NAME________________________________________________DATE_______________APPLICATION SURVEY (Please answer the following questions to help us assess

your needs.) This information will remain confidential. Please circle the answer:

5. The program of courses that I took in high school was designed primarily to prepare me for:

b. a manual trade (auto mechanics, farming, plumbing, carpentry, manufacturing, etc.)

c. a technical trade (electrical, electronics, data processing, commercial art, medical technician, nursing, etc.)

d. secretarial work (typing, filing, dictation, etc.)

e. general commerce (sales, purchasing, banking, bookkeeping, etc.)

f. a college education leading to various occupations

g. other ________________

6. The average of all your grades

during your last two years in high school was approximately:

a. A b. Halfway between A and B c. B d. Halfway between B and C e. C f. Halfway between C and D g. D or lower NOTE: If your school did not use letter grades, do your best to translate your grades into the above system.

7. In high school, which of the following Math courses did you take? (Circle all that apply)

a. Consumer Math

b. Algebra I

c. Algebra II

d. Geometry

e. Pre-Calculus

f. Calculus or higher

8. The average of all my math grades during high school was approximately: a. A b. Halfway between A and B c. B d. Halfway between B and C e. C f. Halfway between C and D g. D or lower NOTE; If your school did not use letter grades, do your best to translate your grades into the above system.

9. The average of all my English grades during high school was approximately: a. A b. Halfway between A and B c. B d. Halfway between B and C e. C f. Halfway between C and D g D or lower NOTE: If your school did not use letter grades, do your best to translate your grades into the above system.

10. What is the highest level of education completed by your mother? a. 9 years or less of elementary school b. some high school but no diploma c. a high school diploma or equivalent d. 1 to 3 years of college (including study at a technical, community, or junior college) e. a 4-year undergraduate college degree (bachelor’s degree) f. a master’s degree g. a doctoral degree

11. What is the highest level of education completed by your father?

a. 9 years or less of elementary school some high school but no diploma

b. a high school diploma or equivalent c. 1 to 3 years of college (including study at a technical, community, or junior college) d. a 4-year undergraduate college degree (bachelor’s degree) e. a master’s degree f. a doctoral degree

Do you have any children?

o NO

o YES If so, how many? Please list their ages: ______________

Please mark Yes or No:

TIME MANAGEMENT I use a daily/weekly/monthly calendar to manage my time. Yes No

I always plan my study time as a top priority and therefore do not

procrastinate when it comes to my school work. Yes No

When I study enough, I still have sufficient time left for social activities. Yes No

For every hour spent in the classroom, I study approximately 3 hours outside of class. Yes No

My studying is very regular and predictable. Yes No

I schedule preparation periods (time set aside to prepare homework)and review periods

(time set aside for reviewing class materials) for each class. Yes No

It is easy for me to say “no” to too many activities. Yes No

After learning about my assignments in class or on my syllabus, I immediately start to work. Yes No

STUDY SKILLS I know how to take good notes in class. Yes No

I normally try to review what I have learned as soon as possible after lectures. Yes No

Regardless of the class, I am usually able to keep up without getting confused,

and my notes are very complete. Yes No

I study all of the assigned readings in my courses. Yes No

I attend all of my classes regularly. Yes No

I talk to instructors/professors about class questions and requirements. Yes No

I complete all work assigned to me. Yes No

I miss out on study time; I immediately apply myself to make up for lost time. Yes No

I take a 5-10 minute break after each hour of concentrated studying. Yes No

I study and review my notes and reading assignments for short periods every day instead of

cramming all information into one day. Yes No

I frequently use information processing strategies such as paraphrasing, summarizing, and outlining. Yes No

As I read textbooks, I highlight and write summary notes. Yes No

I know how to pick out what is important in the text and have no trouble identifying the main ideas. Yes No

When my teachers assign papers, I don’t get overwhelmed, but rather break down the task

into manageable steps. Yes No

I think about potential questions to guide my reading or help me prepare for an exam. Yes No

TEST TAKING SKILLS

I feel that I know effective test-taking techniques. Yes No

In preparing for a test, I review regularly instead of cramming at the last minute. Yes No

On the night before the test, I make a final comprehensive review, and then go to bed early so I

can be rested at the time of the exam. Yes No

When taking a test, I make sure that I fully understand directions before answering any part of the test. Yes No

When taking a test, I look over the entire test and decide how I am going to divide up the time. Yes No

I normally work first in items that are worth the most points. Yes No

I am good at figuring out what material is most important for an exam and what is secondary. Yes No

If I have time left over after a test, I usually review, edit, and check my answers. Yes No

CONCENTRATION

I avoid conversing and engaging in other distracting activities during my study time. Yes No

Concentrating on school work is not an issue for me. Yes No

When studying, I am able to keep my attention clearly focused on the material. Yes No

I have discovered the most productive time and place to study. Yes No

When I try to study, I seldom get bored and quit after a few minutes. Yes No

I normally remain alert during class and get the right material into my notes. Yes No

When I am in class, I listen carefully, evaluate what is being said, and write important notes in my

own words. Yes No

I usually remember/retain the information that I study or read in a chapter. Yes No

COMPUTER SKILLS

Word that best describes my computer skills: non-existing basic intermediate advanced

I use computers at (indicate all that apply): Home CSN Computer Lab Work Friend/relative’s house

I am familiar with at least one word processor application: None Microsoft Word Word Perfect

I have an e-mail account. Yes No

I conduct school related research on the Internet. Yes No

I know how to use a search engine on the Internet. Yes No

I use CSN’s web page to find and register for classes. Yes No

I am familiar with how to take Web CT courses and expect to take a distance education class. Yes No

Name: _______________________________________ COLLEGE READINESS SURVEY

Date: ________________________________________

As you answer the following sets of questions, keep in mind that this questionnaire contains a number of similar items about every topic covered. Each item reduces the chances of error. Therefore, don’t try to recall your previous responses—just answer each question as spontaneously and naturally as you can, without spending a lot of time on any particular one.

Answer each question by circling one number from the following rating scale

RATING SCALE

NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

Thus, if you agree completely with a statement, you should answer with a “7.” Agreement that is fairly strong but not total is indicated by selecting a “5,” while agreement that is fairly weak is indicated by “3.” Total disagreement is indicated by selecting “1.”

ACADEMIC CONFIDENCE

If I have a problem in one of my classes, I continue trying through whatever method necessary (i.e., using a tutor, going to faculty office hours, increasing study time) until I overcome the difficulty.


For the most part, I am always confident that given advance notice, I am adequately prepared for any test.


I tend to put off trying to solve difficult academic problems whenever they arise.


No matter how hard I try, I don’t seem to understand many of the issues in some of my classes.


I am convinced that I eventually master concepts in my academic courses that initially might be difficult to understand.


FINANCING COLLEGE I have financial problems that are very distracting and troublesome. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I have the financial resources that I need to finish college. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I am in a bad financial position, and the pressure to earn extra money will probably hinder my studies.


4

REASONS FOR GOING TO COLLEGE Of all the things I could do at this point in my life, going to college is definitely the most satisfying.


I have some serious misgivings about my decision to come to college. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I am strongly dedicated to finishing college no matter what obstacles get in my way.


I would readily leave college if I found a well paying job. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I am quite confident that my decision to go to college was the right thing for me.


I dread the thought of going to school for several more years and there is a part of me that would like to give the whole thing up.


I wish that society did not put so much pressure on people to go to college, as I’d rather be doing other things at this point in my life.


TACKLING COLLEGE

I often get confused when trying to reach major decisions, and I tend to seek a lot of help with them.


I have declared a major and I feel confident about my decision.


I understand how to follow a degree sheet, its requirements and course sequence.


I have explored the possibility of transferring to a four year institution upon earning my Associate degree.


I often take the initiative in solving my own problems. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I like to explore new ways of doing things, despite the frustrations and disappointments that sometimes result.


TEACHERS

Most of my teachers are very interesting and lively, and they make the learning process quite enjoyable.


Throughout my life, most of my teachers have respected me as a person and treated me fairly.


I like my teachers, they are dedicated, and I feel they do a good job. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

Most of my current teachers have a superior attitude that I find very annoying.


5

CAREER AWARENESS

I am very confused about what occupation to go into. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

In trying to plan a career, I have explored several possibilities and have weighed their advantages and disadvantages.


When I think about my career choice, I find that I have very little solid information to go on, such as the years of schooling and training required.


I have found at least one occupation that seems to fit well with my personality and interests.


I have made a firm decision to enter a certain occupation and have begun planning my life around that decision.


READING & WRITING

My vocabulary is fairly limited, and I have a hard time understanding textbooks.


I never read if I don’t have to. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I like to spend some of my free time reading serious books and articles. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I pick up new vocabulary words quickly, and I find it easy to use them in my speech and writing.


In English classes, I’ve had difficulty analyzing an author’s style, the theme, or the deeper meaning in the reading.


I always look up words I don’t understand. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I am very comfortable writing a very clear and well-organized paper. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I know the difference between a research paper and an essay. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I know how to write a topic sentence and create an outline. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

MATH & SCIENCE

I avoid doing math. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I feel confident that I can succeed in a math class. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I have a hard time understanding and solving complex math problems NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I have a very weak understanding of general biology (e.g., cell structure, metabolism, genetics, and the circulatory system).


I’m very good at understanding the relationship between a scientific principle and a corresponding formula (such as momentum = mass X velocity).


My understanding of the physical sciences (biology, chemistry, physics, etc.) is very weak.


I have a very good understanding of the basic ideas related to atoms, molecules, the periodic table, and chemical reactions.


SOCIAL SUPPORT

I already know several students at CCSN and I feel much more at home. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I make friends easily. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I enjoy activities that bring me into close contact with people. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I am having a hard time breaking away from my family, and attending college makes the situation worse.


I have family problems that interfere (or could interfere) with my studies. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

My parents, or spouse if you are married, have/has paid little attention to my schooling, and haven’t/hasn’t done much to help me.


There is too much tension and emotional turmoil in my family. NOT AT ALL TRUE 1 2 3 4 5 6 7 COMPLETELY TRUE

I feel comfortable discussing important issues with my parents, or spouse if you are married.


Program Release of Information Most family and student information provided to College of Southern Nevada (CSN) TRiO SSS is confidential and will not be released without the student’s permission. TRiO SSS would like your permission to access and release family and student information for the following reasons: TRiO/SSS must report student progress and eligibility information to the U.S. Department of

Education to demonstrate program effectiveness when requesting renewed funding.

Scholarship agencies, leadership, employment and educational programs contact TRiO SSS to offer opportunities to participants. TRiO SSS may release student information (grade summaries, letters of recommendation, etc.) to these entities. TRiO SSS never sells lists of names or other student information.

CSN Financial Aid will provide us eligibility and Financial Aid Award information.

Academic progress monitoring with faculty and instructional support staff for the purpose of

students’ continued academic success and possible intervention by program staff. I give TRiO SSS permission to release information for the above purposes. I verify that all information provided in this application is true and accurate. __________________________________________________________________________________________________________________ Student Name Signature Date

Program Photo/Media Release

Much of our publication and marketing success is from the use of photos and videos taken of TRiO SSS

students during program events. By signing below, you give the irrevocable right to use your name, photo,

or video in all forms and media and in all manners, including composite or distorted representations, for

advertising, trade or any other lawful purposes, and you waive any right to inspect or approve the finished

version(s), including written copy that may be created in connection therewith. I verify that I am at least

18 years of age*, I have read this release and am fully familiar with the contents.

______________________________________________________________________________________________________________________ Student Name Signature Date *(For applicants under 18 years of age) I am the parent or guardian of the minor named above and have

the legal authority to execute the above release. I approve the preceding media release statement and

waive any rights in the premises.

______________________________________________________________________________________________________________________ Parent/Guardian Name Signature (For Media Release Only) Date TRiO SSS, Cheyenne Campus, 3200 E. Cheyenne Ave, N. Las Vegas, NV 89030, (702) 651-4441 tel, (702) 651-4527 fax