Thank you for your interest in our Talent Search program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application.  You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.  If you have any questions, please call our office at 319-398-1048.
Student Information:
Last Name *
First Name *
Middle Name *
Preferred Name
Student Gender *
Date of Birth *
Student's School *
Student's Current Age *
Current Grade Level *
Student Cell Phone *
Student School Email *
Student Address *
City *
State *
Zip Code *
In which area's do you feel you need assistance from TRIO Talent Search? *
After finishing high school, what do you plan to do? *
Ethnicity *
Student Information (Homeless, FostCare, Ward of the Court or N/A) *
Student Citizenship *
Family Information and Income:
Parent 1 Name *
Parent 1 Address *
Parent 1 City *
Parent 1 State *
Parent 1 Zip Code *
Parent 1 Cell Phone *
Parent 1 Email *
Parent 1 Status *
Does the student live with Parent 1? *
Check the box if Parent 1 has a 4-year degree
If checked the box, which college did Parent 1 graduate from? *
Parent 2 Full Name
Parent 2 Address
Parent 2 City
Parent 2 State
Parent 2 Zip Code
Parent 2 Cell Phone
Parent 2 Email
Parent 2 Status
Does the student live with Parent 2?
Check the box if Parent 2 has a four-year degree
If checked the box, which college did parent 2 graduate from?
Total Number of people in household *
Total Taxable Income *

Medical Information and Consent Forms

PLEASE READ THIS CAREFULLY! It affects any rights you may have if your child is injured or otherwise suffers damages as a result of participation in Kirkwood Community College Talent Search sanctioned activities.

During the time Kirkwood Community College Talent Search (TS) or its representatives will be providing field trips, and for other good and valuable consideration, YOU AGREE and state, on behalf of yourself, your heirs, assigns, executors and other, as follows:

  1. I UNDERSTAND THAT the Kirkwood Community College TS project will strive to protect all participants from danger, injuries and abuse during the period they are participating in sanctioned project activities by establishing rules and guidelines for Kirkwood Community College TS participants, staff and representatives.
  2. I UNDERSTAND THAT INJURIES AND DAMAGES to my child are possible, including, but not limited to, injuries common to all of the activities of the Kirkwood Community College TS activity, the risk of property damage and personal injury from motor vehicle accidents, the actions of fellow participants, my child’s own actions or inactions, and also SERIOUS, UNCOMMON, AND UNFORESEEABLE INJURIES, sicknesses, and any other physical or mental effects which may result from my child’s participation; and
  3. I UNDERSTAND AND ACCEPT THE RISK OF ALL (including unforeseeable) INJURIES AND OTHER DAMAGES resulting from or arising out of my child’s participation;
  4. With awareness of an agreement with all of the above, I, on behalf of myself, my heirs, executors, and administrators, agree to RELEASE Kirkwood Community College Talent Search, their officers, faculty members, employees, agents, and volunteers, FROM ANY AND ALL LIABILITY, for ANY INJURIES OR OTHER DAMAGES SUFFERED BY MY CHILD resulting from or arising out of participation in Kirkwood Community College TS; and
  5. That I WILL INDEMNIFY Kirkwood Community College, faculty members, teaching assistants, residence assistants, supervisors, and participants, Kirkwood Community College TS, their officers, employees, agents, and volunteers, FOR ANY Liability OR OTHER DAMAGES suffered by them AS A RESULT OF MY CHILD’S ACTIONS.
  6. I state that my child under my legal custody ___does have a current health insurance policy, and such policy will be maintained for the duration of all Kirkwood Community College TS activities. 

If the below named participant is in need of medical attention, as the result of either illness or injury, I do hereby give my permission for Kirkwood Community College and Kirkwood Community College TS to provide, or see that the necessary care is provided. Additionally, I give the College permission to submit my medical insurance information to any medical provider caring for the minor child.

By signing this form, I STATE THAT I HAVE READ AND UNDERSTAND THE CONDITIONS SET FORTH IN THE CONFIDENTIAL RELEASE FORM AND THE RELEASE AND CONSENT FORM, THAT I AGREE TO ALL CONDITIONS SET FORTH HEREIN, AND THAT I SIGN THIS VOLUNTARILY.

I have read and understand this *

You hereby consent to the use of photo, video, or other media recordings taken of your child by Kirkwood Community College or those acting on its behalf for the benefit Kirkwood Community College, including any lawful purpose whatsoever, including but not limited to use in any Kirkwood Community College publication or on Kirkwood Community College websites, without payment or any other consideration. You hereby waive any right that you may have to inspect and/or approve the finished product or the copy that may be used, or the use to which it may be applied. You do this with full knowledge and consent and waive all claims for damages. 

 
Media Consent (Yes or No) *

 By signing this application: 
1. You hereby give your permission to the Kirkwood Community College’s Talent Search Program to request and receive confidential information pertaining to any and all financial assistance awarded to you or your child (if under 18). 

2. You also hereby release and discharge: 
a. Any agency and/or person(s) from any liability for divulging such information to Kirkwood Community College’s Talent Search Program (Kirkwood Community College TS). 
b. Kirkwood Community College’s Talent Search program and staff from any liability for divulging such information to any admission and financial aid offices at degree-granting institutions (i.e., colleges, universities, community colleges, and vocational/technical schools) and other agencies which aid Talent Search participants. 

3. You give permission to your child’s school district to release his/her school schedules, records and grades periodically to: 
Kirkwood Community College 
TRIO Talent Search, Linn County Regional Center
302 Main Office
1770 Boyson Road, 
Hiawatha, IA 52233

4. You agree to cooperate with the KIRKWOOD COMMUNITY COLLEGE TS staff in follow-up activities, including the release of school records. These follow-up activities will continue throughout middle school, high school and college. 

 
I have read and understand this *
_________________________________________________________________________________________________________________________________________________________________________________________
By signing this, the student and parent/guardian(s) agree that everything submitted on this application is true to their knowledge. 
Parent/Guardian Signature *
Signature Type: Email    Start Over
After validation, the email address will become part of the electronic signature.
Email:
 
Student Signature *
Signature Type: Email    Start Over
After validation, the email address will become part of the electronic signature.
Email: