Eastern Kentucky University-TS

Eastern Kentucky University
Educational Talent Search Application
Educational Talent Search Program
Telford House, 521 Lancaster Avenue
Eastern Kentucky University, Richmond, Kentucky 40475
Phone: 859-622-5425 FAX: 859-622-5033
Email: ETS@eku.edu Web Address: http://www.ets.eku.edu

Complete all 5 sections with Required Student Signature in Section 3 and Required Parent/Guardian Signature in section 2, 4 & 5.

SECTION 1 - Student Information
Student's Full Official Name*

First NameMiddle NameLast Name
Goes by
Home Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
For important ETS communications, we use the Remind text messaging & email.
Home Phone
(999)999-9999
May we text this number?

YesNo
Student Cell Phone
(999)999-9999
May we text this number?

YesNo
Student Communication E-mail Address*
example@example.com
Parent Communication E-mail Address
example@example.com
Student has access to a home computer:

YesNo
Student has access to home Internet:

YesNo
Student is a U.S. Citizen, National, Permanent Resident or in process of US Citizenship:

YesNo
ETHNIC BACKGROUND (Ethnic information is for statistical data only, and is not a factor in program eligibility):
Please select ALL that apply:

American Indian/Alaskan NativeAsianAfrican American/BlackHispanic/LatinoNative Hawaiian/Pacific IslanderCaucasian/WhiteOther
Student identifies as:

he/himher/shethey/them
Student’s age as of 9/1/2023
Date of Birth (required)

MonthDayYear
mm-dd-yyyy
As of September 1, 2023, what is student's grade:

9610711812
Name of School or Homeschool
Cumulative Grade Point Average (GPA)

OR the number of most recent letter grades:

	Number
A's
B's
C's
D's
F's

Student has the ability and desire to continue education beyond high school (college/vocational/trade school)

YesNo
Student can only participate in one TRIO Program at a given time (Educational Talent Search, Upward Bound (UB), or UB Math Science)

Student is not a participant in any other TRIO ProgramStudent is a participant in UB or UB Math Science, but wishes to transfer to the EKU Talent Search Program
Does Student have any special needs you would like to report:
Does student have a 504 with the school

SECTION 2 - Parent/Guardian Information
Student Lives With:

Both Birth/Adoptive ParentsSingle Birth/Adoptive ParentBirth/Adoptive Parent & Step-parentStudent does not live with a birth or adoptive parent.
Please indicate the type of guardianship below:

Court Appointed (Foster or Legal) Guardianship (must attach copy of guardianship documents)Family Guardian, no court or legal document, but I have Educational/Medical Rights for said student.
Attach copy of guardianship documents

Browse Files

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PARENT/GUARDIAN INFORMATION

Parent/Guardian #1
Parent/Guardian #1: Full Name

First NameLast Name
Relationship to Student
Cell Phone Number
(999)999-9999
May we text parent/guardian #1?

YesNo
Parent/Guardian #1 Email Address
example@example.com
May we email this parent/guardian?

YesNo
Work Phone Number
(999)999-9999
Parent/Guardian #1 Occupation
Facebook Name
Did parent/guardian #1 graduate with a 4-year, Bachelor college degree?

YesNo
Name College and Year of Graduation
Parent/Guardian #2
Parent/Guardian #2 Full Name

First NameLast Name
Relationship to Student
Cell Phone Number
(999)999-9999
May we text parent/guardian #2?

YesNo
Parent/Guardian #2 Email Address
example@example.com
May we email this parent/guardian #2?

YesNo
Work Phone Number
(999)999-9999
Parent/Guardian #2 Occupation
Facebook Name
Did parent/guardian #2 graduate with a 4-year, Bachelor college degree?

YesNo
Name College and Year of Graduation
How many people live in your household including students away at college.
Did the family file a Federal Income Tax Report last year?

YesNo
Please indicate your TAXABLE INCOME RANGE (this is your income after deductions are taken out). Your Taxable Income can be found on last year’s federal income tax form 1040, line 15. (revised 8/15/2023).*

1. $0 to $21,8702. $21,871 to $29,5803. $29,581 to $37,2904. $37,291 to 45,0005. $45,001 to $52,7106. $57,711 to $60,4207. $60,421 to $68,1308. $68,131 to $75,8409. $75,841 or above
YES, the above marked taxable income is from line 15.

YesNo
Please attach a signed copy of last year's federal tax form:

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Student Receives School Free Breakfast/Lunch:

YesNo
Please indicate all sources of family income

ALIMONYCHILD SUPPORTDISABILITY SSIEMPLOYMENTRETIREMENTUNEMPLOYMENTSOCIAL SECURITYSURVIVOR’S BENEFITSSOCIAL SERVICES K-TAPP/ SNAP/Food Stamps/ HUDVETERAN BENEFITSOther

Names of Other School Age Siblings in Home

	Name	School	Grade	Is In ETS
Sibling #1
Sibling #2
Sibling #3
Sibling #4

I give permission for (student’s name) ___________________________ to participate in the Educational Talent Search (ETS) Program through Eastern Kentucky University. I verify all of the information on this application is true and to the best of my knowledge, correct.

First NameLast Name
Parent/Guardian Signature (Student may sign if they are 18 years of age or older)

Clear
Today's Date

MonthDayYear
mm-dd-yyyy
Student's Goal For After High School

College/UniversityCommunity Technical CollegeVocational/Trade SchoolMilitaryI don't know
Student is interested in the following career or field of study:
Student is interested in the following schools/college:
Student's Need for ETS Services: Below are services offered by the Educational Talent Search Program. Indicate services the student wishes to receive.

Test prep, study skills & strategiesHigh school preparation & class selection advisingCollege planning informationCollege Admission Application processFinancial Aid programs & applicationsMoney ManagementPersonal skill developmentCareer options & awarenessCultural opportunity activitiesSTEM (science, technology, engineering & math) activitiesConnection to academic tutoringExposure to college, career, and cultural sites.
If accepted into the Educational Talent Search Program as an ETS Scholar, I will do my best to:
- Participate in ETS Activities as much as possible.
- Maintain open communication with my ETS Coordinator.
- Check my e-mail regularly.
- Maintain at least a 2.5 cumulative grade point average or better, to remain in ETS Good Standing.
I would like to participate in ETS Activities via the following opportunity venues. (select all that apply)

In-School Workshops (if possible)Other In-Person ActivitiesOnline InteractionsVia Mail Exchange
Student's Signature

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
PUBLICITY PERMISSION

I give permission for the EKU Educational Talent Search (ETS) Program, its employees and volunteers to record my/my child’s likeness and voice on video, audio, photographs, electronic medium, or other news sources and mediums to:
- Recognize ETS participants and increase awareness about ETS services and activities;
- Share group photos on social media (i.e. Facebook, Instagram, Twitter), brochures, and to recognize student achievement in press releases.
Student Signature

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

SECTION 3 - Educational Records Release
EDUCATIONAL RECORDS RELEASE

The Family Educational Rights and Privacy Act of 1974 (FERPA), as amended, is a federal law that protects the privacy of student education records. The Educational Records Release is required for participation in the Educational Talent Search Program. By completing this authorization, I give permission for the Educational Talent Search (ETS) Program at Eastern Kentucky University to have access to all middle school/high school, student educational related records of:
Student Full Name*

First NameMiddle NameLast Name
Student's Date of Birth*

MonthDayYear
mm-dd-yyyy
I understand, the student’s Educational Records Release must be signed in order for the student to receive services from the Educational Talent Search Program (ETS).

Student educational record information may be used to:
- determine eligibility to receive services from the ETS Program,
- monitor status and progress in secondary school
- guide student regarding academic advising,
- communicate with school personnel regarding the needs of the student.
- Track post-secondary education attendance and completion.
I give the Educational Talent Search Program, permission to have access to my child’s middle school/high school information in the school data system (Infinite Campus). Necessary records may include, but are not limited to information in the secondary educational records such as grade reports/transcripts, test scores, attendance, behavior reports, medical, court documentation and other records. It is my understanding that these records will be released only to those who have legitimate educational interest, or otherwise are required by law to be disclosed by EKU.

I understand the Educational Records Release can be revoked at any time by submitting a written request to the Educational Talent Search Program at Eastern Kentucky University.
Parent/Guardian Signature (Student may sign if 18 years of age or older)*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy