NEW STUDENT APPLICATION

2025-2026 Academic Year

Florida Gulf Coast University

10501 FGCU Boulevard S.

Fort Myers, FL 33965

Phone: 239-590-7834   

Fax: 239-590-7947

https://www.fgcu.edu/trio/outreachprograms/

Selection Process & Eligibility Requirements

Only COMPLETE applications will be reviewed. After the initial screening, eligible applicants will be notified by e-mail.

If you should have any questions about this process, please do not hesitate to contact us at 239-590-7834.

 

Part 1: Student Information
First Name *
Middle Name
Last Name *
Preferred Name
Address *
City *
State *
Zip *
County *
Student Cell Phone *
Student Email Address *
Date of Birth *
Current Age *
Gender *
Residency Status *
Race *
Ethnicity *
First Language *
Do you speak English at home?
Current School *
Current Grade Level *
School ID *
Are you taking any Honors/Dual Enrollment/Advanced Placement/International Baccalaureate courses? *

Part 2: Needs Assessment
1. Are you in need of assistance with your academics for better grades?
2. Are you in need of assistance for better study skills development?
3. Are you in need of one-on-one or group tutoring?
4. Do you need help preparing for state testing or college placement tests?
5. Do you need help choosing your classes?
6. Do you need help deciding what your milestone courses are?
7. Is English your first language? 
8. Do you need help deciding your career path?
9. Do you need help exploring your career options? 
10. Do you need help with financial aid, scholarship search, FAFSA, or college applications?

Part 3: Family Information

(To be completed by Parent or Guardian)
With whom does the student live with? *
Parent/Guardian (#1) First and Last Name *
Relation *
Cell Phone Number *
Work Phone Number
Email Address *
Highest level of education completed in the United States *
Parent/Guardian (#2) First and Last Name
Relation
Cell Phone Number
Work Phone Number
Email Address
Highest level of education completed in the United States
Is your child eligible for the free lunch program at school? *
Number of people living in house *
What is your household taxable income in 2024? *
My signature confirms that the information above is accurate.
Parent/Guardian Signature *
Signature Type: Simple    Start Over
Signature: (Type in your full name)
I agree to the terms included.

Part 4: Parent/Student Consent

CONSENT FOR SERVICES:

I understand pre-college and educational outreach services, including but not limited to: academic advising, tutoring, cultural enrichment activities, career and college exploration, will be provided as needed. Services are provided by TRIO & Outreach Programs staff (counselors, volunteers, mentors, tutors and teachers), and are designed to help students achieve their academic and personal goals. These services are provided free of charge and at the student's will. ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT.

RELEASE OF INFORMATION:

I authorize TRIO & Outreach Programs personnel to access academic and personal information in the legitimate educational interest of my student including but not limited to: public assistance, free & reduced lunch documentation; standardized test scores (State testing scores, SAT, ACT, GED); report cards; unofficial and official transcripts; attendance records; information about the status of post-secondary education admission/enrollment; financial aid documentation including FAFSA pin code, SAR, and award letters in accordance with The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99). I understand this information is essential in assisting me/my child in preparation for post-secondary education. I further understand all information received is for TRIO & Outreach Programs use only and is held strictly confidential. I intend to give permission for TRIO & Outreach Programs personnel to access and collect this information for the duration of my student's participation in the program and throughout his or her high school and college career; however, if I choose to withdraw this permission, I can call the Program Director at (239) 590-7834

BEHAVIOR AGREEMENT:

I understand that the rules I am held responsible to at my school campus are the same rules that apply during any event with the TRIO & Outreach Programs. If any rule is broken, I understand if it becomes necessary, the TRIO & Outreach Programs staff will call my parents, and they will be required to pick me up IMMEDIATELY. I also understand that failure to abide by any of the recognized rules may result in my dismissal from the TRIO & Outreach Programs.

IMAGE (MEDIA) RELEASE (Please read carefully):

I give TRIO & Outreach Programs permission to record my child's participation and appearance in digital or electronic recordings, videotape, audiotape, film, photography, or any other medium to use my child's name, likeness, voice, and biographical information in connection with these recordings. FGCU may make exhibit or distribute all or any part of these recordings for any educational or promotional purpose, which the university deems appropriate. All such recordings shall remain the university's property.

 

WAIVER OF LIABILITY

As parent and/or legal guardian of the above-mentioned student, I authorize and permit my child to participate in field trips, activities, and events offered by the TRIO & Outreach Programs. I understand that my child may be leaving his/her school campus or FGCU (Florida Gulf Coast University) and may be transported by the TRIO & Outreach Programs staff of Florida Gulf Coast University. I agree that FGCU, TRIO & Outreach Programs, and anyone associated with FGCU will not be held liable for any loss, injury, or death related to any field trips or events and I may be required to sign a General Participation Release. Further, I agree to hold harmless FGCU, TRIO & Outreach Programs, Advisory Committee members, officers, staff, and volunteers, from any claims whatsoever occasioned by the services provided and that TRIO & Outreach Programs at Florida Gulf Coast University shall not be held liable.
Emergency Contact:
Name *
Phone Number *
I consent and verify the information provided above is true and complete to the best of my knowledge.
Student Signature *
Signature Type: Simple    Start Over
Signature: (Type in your full name)
I agree to the terms included.
Parent/Guardian Signature *
Signature Type: Simple    Start Over
Signature: (Type in your full name)
I agree to the terms included.