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CLINCH VALLEY COMMUNITY ACTION
Project Discovery Student Application / Intake

Please Complete All of the fields of the applications and mark if the information is Not Applicable (N/A).  Failure to provide information could cause delay in enrollment.

Student Contact Information
Disabled
U.S. Citizen
Naturalized Citizen
Enrolled in Advanced Curriculum
Household Information
Father/Father Figure
Custody
Disabled
Citizenship
College Graduated
Mother/Mother Figure
Custody
Disabled
Citizenship
College Graduated
Income Information

Project Discovery receives a variety of funding to provide services. These funding sources require evidence of income levels of households services are provide.  This information is kept confidential (as all personal information) and used for verification.  Household income levels do not reflect or change the services provide to students.  There are three different ways to provide your income.  Please check the following method and complete the information.  If you have questions, please contact us.


Verification Method

Please submit proof your household income for at least 30 days.  

Period:  Yearly, Monthly, Bi-Monthly x 26 weeks, Bi-Weekly x 24 weeks, Weekly

Type of Documentation Provided:(Current)
I certify that I currently do not receive any documentable income
Household Benefits

I certify that the all information is accurate and correct.  I understand the following:  1) Income Verification is a requirement for my child to be enrolled in the program, 2) The information will not affect the type of services provided. 3) Program officials may verify information on this form. 4) Any person who knowingly provides false or fraudulent information may be subject to arrest and prosecution. 

Addition Household Member
Disabled
Citizenship
College Graduated
Year Graduated
Addition Household Member
Disabled
Citizenship
College Graduated
Year Graduated
Addition Household Member
Disabled
Citizenship
College Graduated
Year Graduated
Addition Household Member
Disabled
Citizenship
College Graduated
Year Graduated
Parent Involvement

Clinch Valley Community Action-Project Discovery believes a key in your student's journey to post-education is your involvement.

Please select below any of the activities or events that you would be willing to participate.
Consent to Exchange Information

I understand that different agencies provide different services and benefits.  Each agency must have specific information in order to provide services and benefits.  By signing this form, I am allowing Clinch Valley Community Action, Project Discovery to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I can withdraw this consent at any time in writing to referring agencies.  This will stop them from sharing information after they know my consent has been withdrawn.  I have the right to request to be notified when and what information has been shared.   I want the school system to accept a copy of this form as a valid consent to share information.  By not signing, information will not be shared and I will be contacted by {AGENCY}—Project Discovery to provide needed information.

Crisis/Thrive Self-Sufficiency Assessment

These questions are designed to give us statistical data for the purpose of improving services for our community.


In each category please select the one that is closest to your current situation.

Food & Nutrition
Housing
Childcare
Transportation
Financial Management
Program and Student Responsibilities

Clinch Valley Community Action, Project Discovery is a college access for students in grades 6th – 12th.  The program is designed to help students prepare for their future goals.  Student’s take the responsibility of preparing for their future and Project Discovery take the responsibility of providing the skills and resources for students.   

Project Discovery responsibilities:

1)   Provide workshops on life topics. Workshops offered but no limited to:

2)   Goal setting, study skills, college selection/admission, financial/scholarships, financial literacy, personal well-bring, anti-bullying, leadership, life skills, legislative understanding, test taking.

3)   Provide fee waivers for college applications and sat/act testing.

4)   Provide resources for your college/career planning.

5)   Assist with completed of financial aid applications.

6)   Assist with researching and completing scholarship applications.

7)   Provide opportunities and experiences such as college camps.

8)   Provide opportunities for community projects.

9)   Provide campus visits to colleges to learn firsthand the college offerings.

10)  Provide trips to culture/social, sporting, recreational events to promote social skills and self-esteem.

11)  Provide a college night once a year that includes college representatives and valuable information.

12)  Provide a career exploration event of student career interested.

13)   Provide a Virginia 529, Soar Virginia scholarships to those students who meet that programs eligibility.

14)  Provide one-on-one counseling when requested.

15)  Provide guidance and skills to handle life as a college student.

16)  Provide parents/guardians with information about the program and activities.

17)  Provide transportation for all activities such as colleges, activities, events.

18)  Provide meals, activity cost, and accommodation at no cost.

19)  Provide bonus trip scheduled by project discovery staff, if one is offered and funding available.

20)  Provide resource for tutoring.

21)  Provide a certificate of recognition upon completion of Project Discovery program requirements.

22)  Provide all services at no cost to the student or family.

Student responsibilities:

1)    To conduct myself in a manner as to demonstrate a positive image of myself, my school, and Project Discovery during activities. To follow the program and schools code of conduct at all times. Be respectful to others, such as students, staff, special guest, etc.

2)   To provide parents with all information and forms given.

3)   All necessary documents are completed and returned before the deadline.

4)   Be an active participant in all workshops, trips, events, fundraisers, and community service.

5)   Attend at least 80% of all activities and allocate enough time for activities.

6)   Provide a copy of grades at the end of each 6 weeks.

7)   Update staff on changes in your class schedule, personal information, and other changes.

8)   To notify Project Discovery staff in the event that I am unable to attend a workshop or trip, such as but not limited to work, serious injury or illness, family situation, tutoring.

9)   To help with recruiting other students that would benefit from the programs.

10)  To help keep state and local officials aware of the program and the services you receive.  By information sessions and formal contact (letters, emails, calls, etc. with officials.

11)  To encourage parents and guardians to become more involved with program.

12)  To provide Project Discovery with grades, GPAs, class schedules.

13)  To provide update contact information as it changes, such as address, phone numbers, emails, etc.

14)  To provide update on class schedule, employment, and other changes.

15)  To contact Project Discovery staff with issues we could help you with resources we have available.

certify that I have read above information and agree to be an active member of the program.  I understand that Project Discovery reserves the right to amend contract due to changes in program services and requirements.

Student Medical

All information is strictly confidential and used only in case of an emergency.

Student Medical Information:  Does your child have any of the illnesses, diseases, or conditions? (Please leave blank if it does not pertain to your child.)

Diabetes Type 1:
Diabetes Type 2:
Asthma:
Epilepsy
Sickle Cell Anemia:
Heart Disease:
HIV:
AIDS:
Depression:
Attention Deficit:
Hypertension Disorder:
Other:
Is your child allergic to latex?
In case of emergency, does Project Discovery have your permission to 1) provide emergency care (CPR/First Aid) and 2) take your child to hospital /medical facility to receive treatment?
What type of insurance does your child have? (Please List)
Medical Information and Permission Form

I grant the following permissions to Project Discovery of Virginia, Inc. concerning my child named above;

  • permission to transport my child to and from activities
  • permission to seek medical care for my child in an emergency
  • permission to review my child’s permanent school record and any other school record necessary to assist my child or to maintain eligibility for this program
  • permission for my child to participate in the promotion of Project Discovery
  • permission for my child’s written statements or photos while in Project Discovery can be used in the promotion of Project Discovery including social media.

I understand that all information given in this application and medical form is STRICTLY CONFIDENTIAL and no information will be released without my approval

Parent/Guardian Acknowledgment: I further understand that my child is expected to adhere to the Project Discovery rules of conduct, and those of the school at all times. These rules forbid the use illegal substances or alcohol or engaging in any activity consider to be detrimental to the group or the individual. I understand that I will be required to pick up my child immediately if an infraction occurs.

Student Acknowledgment:  I, as a participant in Project Discovery, understand that I am expected to adhere to the Project Discovery rules of conduct, and those of the school at all times. These rules forbid the use illegal substances or alcohol or engaging in any activity consider to be detrimental to the group or the individual. I understand that my parent/guardian will be notified and required to pick me up immediately if an infraction occurs.

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