Phone Number
Thank you for your interest in our TRiO/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 (561) 868-3638.
General Information:
Last Name *
First Name *
Middle Name
Date of Birth *
Race/Ethnicity
Address *
Address 2
City *
State *
Zip *
Phone
Cell Phone
Email
Describe your primary reason for applying
Academic Information:
Current Grade Level *
Current School *
Current Age
Family Information:
Parents Education Level *
How many people in your household? *
Household Income Range (Go to line 15 of your tax paper,1040, form) *
Copy of Green Card/Citizenship document if not born in the U.S. (copy of first page of U.S. passport, certificate of citizenship, Residence card)
Please, select your Status (You must be a U.S. Citizen or Permanent Resident to be eligible.) *
Sign and Submit:
Applicant Signature *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Parent/Guardian Signature *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Please read and sign if you agree to the following terms.

I give my permission to release to PBSC Talent Search all information pertinent to my educational program including a copy of my nine week grades, progress reports, test scores, graduation status, financial aid application, transcripts, college enrollment status, awards from state and federal funding agencies, post-secondary institutions, and the National Student Clearing House.  I also give the Talent Search Program permission to request other documents as necessary to assist me with my admission and enrollment in post-secondary education and financial aid application and awards.

Photograph of our participants may be included in our website or possibly other college approved media.  We require your authorization to use any photos we take of your student in order to do this.

Please read and sign if you agree to the following terms.

I hereby irrevocably consent to and authorize the use and reproduction by Palm Beach State College or any person or organization authorized by Palm Beach State College of any and all photographs, video tapes, or film which have been taken of my student, both singularly and as part of a group, without any compensation to me. All positives and negatives shall constitute solely the property of Palm Beach State College.
Approval of Parent/Guardian *

The undersigned parent or legal guardian of the applicant who is currently enrolled in High/Middle School, hereby grants permission for his/her student to participate in activities sponsored by Palm Beach State College's Talent Search B Program.

The undersigned does further join in the release of Palm Beach State College, its trustees, officers, employees and agents from any and all liability or claims for losses or damages that the student may sustain while participating in travel activities sponsored by the Palm Beach State College's Talent Search B Program.  The undersigned expressly understands and agrees that Palm Beach State College, its trustees, officers, employees and agents assume no liability for the student's participation in travel activities.

The undersigned grants authority of Palm Beach State College's representative to authorize medical treatment as the treating or consulting physician deems to be necessary while participating in the college's travel activities.  Therefore, the undersigned releases Palm Beach State College, its trustees, officers, employees and agents from any liability or claims for damages arising from the exercise of the authority granted.
Parent/Guardian Aproval *
Should my student become ill or be involved in an accident, while in Palm Beach State (PBSC) Talent Search sponsored activities; PBSC's representative will make every attempt possible to notify me of circumstances of the incident.  If PBSC cannot reach me immediately, or if the situation is such that it warrants immediate medical attention, I grant PBSC's representative authorization to secure medical treatment for my student. It will be my responsibility to assume payment for such medical treatment.
Contact 2 Name
Cell Phone
Contact 2 Work Phone
Student ID (PB number)