PARTICIPANT APPLICATION
Participant Information
Name:
Address:
Telephone: Social Security:
Date of birth: Age: Homebase:
School: Grade: Other:
Section II
Ethnic Background
African American Male: Female:
Hispanic/Latino/Latina
Asian/Pacific Islander
American Indian
White Non-Hispanic
Other
Colleges interested in:
Careers interested in:
Section III
Please check the following services that you would like to receive from Educational Talent Search:
Career/job information
College visitation information
Career visits
Financial Aid information
SAT/ACT preparation
Cultural Awareness
Tutoring
Post-Secondary exploration
Academic awareness/goal setting/study skills
College/technical/vocational school information
Personal awareness/self-esteem
Section IV
Please list two persons to contact in case of an emergency:
Name: Relationship: Phone:
Section V
Family Information
Please check the blank that reflects your family’s taxable income (line 37 on form 1040; line 22 on form 1040A).
$0-11,610
$11,611-15,540
$15,541-19,470
$19,471-23,400
$23,401-27,330
$27,331-31,260
$31,261-35,190
$39,191-39,120
Social Security, AFDC, child support, worker’s com., veteran’s benefits etc.
Number in household:
Is your family eligible for: free lunch reduced lunch
Mother’s name: Four-year college degree: Yes No:
Father’s name: Four-year college degree: Yes No:
Guardian’s name:
With whom does the applicant reside:
I (We) the Parent(s)/Guardian(s) of said child grant permission to participate in the Educational Talent Search Program. I also give permission for said child to take field trips as part of the Educational Talent Search Program. Educational Talent Search will provide transportation for field trips. Parents will be notified of every out of school activity and event in which your child may participate.
I authorize the Educational Talent Search Program to access my child’s report cards, test scores, transcripts and other relevant information for my child’s eligibility to participate in the program. I also allow the Educational Talent Search Program to photograph my child during activities for use in newsletters, brochures and/or press releases. All information obtained by the Educational Talent Search Program will be held in complete confidence.