Students interested in joining Century College TRIO ETS should have a parent or guardian complete this form.

All information is confidential and protected by the Family Educational Rights and Privacy Act and is not specifically reported to the federal government or the U.S. Department of Education. However, the U.S. Department of Education does have the authority to gather general statistical information about the program participants in order to improve and measure the success of the Educational Talent Search Program.

Do you have questions or concerns? Please contact the TRIO ETS Team:

  • General office line: 651-779-3980
  • TRIO ETS Director, Aarin Distad: 651-779-3980, aarin.distad@century.edu
  • Hazel Park/Harding Advisor, Serena Vang: serena.vang@century.edu
  • Battle Creek/Harding Advisor, Bryan Thaoxaochay: bryan.thaoxaochay@century.edu
  • Farnsworth Upper 5-8/Johnson Advisor/Assistant Director, PaDee Vue: padee.vue@century.edu
  • Afterschool Coordinator, Pete Wong: pete.wong@century.edu
Student Information:
Last Name *
First Name *
Middle Name
Date of Birth *
Student CIF Number (school lunch number)
Race/Ethnicity
Address *
Address 2
City *
State *
Zip *
Phone
Cell Phone
Email
Which of the services that TRIO ETS provides does the student need the most assistance with? *
Please list any additional needs the student may have.
Student Social Security Number
Is the student a citizen or permanent resident of the United States of America? *
Academic Information:
Current School *
Current Grade Level *
Current Age
Family Information:
Parent/Guardian Name 1 *
Parent/Guardian 1 Relationship to Student
Parent/Guardian 1 Phone
Parent/Guardian 1 Email Address
Does the parent want to receive email newsletters from TRIO ETS?
Parent/Guardian 2 Name
Parent/Guardian 2 Relationship
Parent/Guardian 2 Phone
Parent/Guardian 2 Email
Who does the student live with most often? *
Parent/Guardian 1 Education Level *
Parent/Guardian 2 Education Level
Taxable income (necessary for Federal Grant Regulations) Form 1040, line 15 *
How many people live in your household? *
Most Recent IRS 1040

Release of Records/Media Release/Information Validation

I certify that the information I have provided is complete and correct to the best of my knowledge. Century College Educational Talent Search has my permission to access the following information for the purposes of determining program eligibility and the reasons specified; Transcripts/test scores for advising purposes and to assess credits and graduation process; Class schedules to contact and involve students in program services and activities; Enrollment data to verify target school attendance; Free/Reduced Lunch data to verify program eligibility. I also give permission for the use of my child's name and/or photograph for editorial, promotional, recruitment or educational purposes. I understand I may withdraw permission to access information at any time through written notification.

The Release of Records is essential and required in order for Century College TRIO/ETS staff to gather student data for purpose of reporting to the U.S. Department of Education. Therefore, I/we authorize ETS representatives to communicate with representatives from post-secondary institutions on my behalf for up to six years post high school graduation. This also authorizes the post-secondary institution in which said student is enrolled to release information about admissions, college academic enrollment and degree completion.

This information is used for program reporting and verification of post-secondary completion. This information is private and protected under the General Education Provision Act as well as the Family Education Rights and Privacy Act.
Sign and Submit:
Student Signature
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.
Parent/Guardian Signature *
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.
How did you hear about our program?
Please share the name of the student or staff who told you about TRIO ETS.