Homework Club Application

Page 1

Hidden Fields

Status

Name & Contact Information

First Name

STUDENT'S Legal Name

Preferred First Name

STUDENT'S Preferred First Name

Middle Name

Last Name

STUDENT'S Last Name

Address

Mailing Street Address

Mailing City

Mailing State/Province

2 letter state abbreviation

Mailing Zip

Personal Email

Home Phone

(###)###-####

Mobile Phone

(###)###-####

By providing mobile numbers on this form, I am providing my electronic signature expressly authorizing First Generation College Bound to contact me by email, text, or phone (including an automatic dialing system or artificial/prerecorded voice) at the home or mobile phone number above. I understand I am not required to sign or agree to this as a condition to service. I may opt out to text messaging by texting "STOP."

I agree

Social Security Number

Residence & Guardian

Who do you reside with?

Is this person your legal guardian?

Is legal guardian documentation available?

Additional Personal Information

Gender

Date of Birth

MM-DD-YYYY

Ethnicity

Do you have a disability?

Please elaborate

Do you have an IEP?

By providing mobile numbers on this form, I am providing my electronic signature expressly authorizing First Generation College Bound to contact me by email, text, or phone (including an automatic dialing system or artificial/prerecorded voice) at the home or mobile phone number above. I understand I am not required to sign or agree to this as a condition to service. I may opt out to text messaging by texting "STOP."

I agree

Page 2

School Information

Homework Club Site

Current School Attending

Student School ID#

Student receives

Anticipated High School Graduation Year

Conclusion of senior year of high school. Due to graduate in May 2026? > 2026

Current Grade

Current Grade Point Average (GPA)

If applicable

First & Last Name of current guidance counselor

Page 3

Parent/Guardian #1

Parent/Guardian 1 Marital Status

Prefix

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent/Guardian 1 Relationship to student

Parent/Guardian 1 Address

Mailing Street Address

Mailing City

Mailing State/Province

2 letter state abbreviation

Mailing Zip

Contact Information

Parent/Guardian 1 Cell Phone

(###)###-####

Parent/Guardian 1 Home Phone

(###)###-####

Parent/Guardian 1 Work Phone

(###)###-####

Parent/Guardian 1 Email Address

Parent/Guardian 1 Best Contact Method(s)

Parent/Guardian #2

Parent/Guardian 2 Marital Status

Prefix

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Relationship to student

Parent/Guardian 2 Address

Mailing Street Address

Mailing City

Mailing State/Province

2 letter state abbreviation

Mailing Zip

Contact Information

Parent/Guardian 2 Cell Phone

(###)###-####

Parent/Guardian 2 Home Phone

(###)###-####

Parent/Guardian 2 Work Phone

(###)###-####

Parent/Guardian 2 Email Address

Parent/Guardian 2 Best Contact Method(s)

By providing mobile numbers on this form, I am providing my electronic signature expressly authorizing First Generation College Bound to contact me by email, text, or phone (including an automatic dialing system or artificial/prerecorded voice) at the home or mobile phone number above. I understand I am not required to sign or agree to this as a condition to service. I may opt out to text messaging by texting "STOP."

I agree

Page 4

Household Information

Annual Combined Household Income

Tax Documents or Proof of income may be required.

Total # of Dependents in Household

Total # of Persons Living in Household

Parent(s) Highest Level of Education Earned

Emergency Contact Information

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

(###)(###)(####)

Emergency Contact's Relationship to Student

Application Consent

I understand that my son/daughter is enrolling in First Generation College Bound, Inc. Homework Club. The program is designed to assist my son/daughter with school work and if a senior in high school, in the college application process. I understand that FGCB is not a scholarship organization. I have completed, understood and signed the Release of Information form.

Parent/Guardian's Consent

I agree

Page 5

FGCB Release of Information

I hereby authorize the release of the following information from my school and other agencies that provide services to me to First Generation College Bound, Inc. (FGCB). Further I authorize the sharing of this information among FGCB personnel and its subcontractors to assist me and my family to meet my educational goals. I understand that the information will be held in confidentiality in accordance with standards set forth in the Privacy Act and other subsequent laws governing privacy and confidentiality. I further understand that any reports generated will be done in the aggregate (no names or other identifying information will be used).

Select YES or NO.

Education information, including copies of report cards, class schedules, test scores, transcripts, diplomas, certificates, and/or degrees.

Social history data, including family financial/economic and education status information for grant reporting purposes and data collection.

Medical information to ensure appropriate treatment while engaged in FGCB activities.

Page 6

Purposes

Information may be exchanged either verbally (in person and/or by phone) or in written form. I understand this information will be used for the following purposes.

Select YES or NO.

Development of the individualized college success plan including educational goals, personal development goals, support service needs, career goals and financial planning.

Referral for support services, such as financial assistance, education services, substance abuse treatment, family counseling, etc.

Coordination of educational and support services.

Presentation at professional staff meetings to determine progress in meeting planned goals and identification of additional supports as required.

Parent/Guardian's Consent

I agree

Consent

I understand that this authorization remains in effect through the duration of my enrollment in FGCB and that it may be revoked at any time by written statement. I understand that FGCB’s program activities may be taped and photographs may be taken for instructional as well as publication purposes. This allows the work being done by members of the program to share their accomplishments with others. I hereby authorize FGCB staff to release the above-related information. I also understand that I can revoke this consent by written notice.

Parent/Guardian's Consent

I agree