Shawnee Community College-TS

Household Information
With whom do you live?

MotherFatherBoth ParentsAdoptive ParentsSelf
Name of Legal Parent(s)/ Adoptive Parent(s)
Mailing address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ETS is required to verify that our participants meet federal criteria based on education background and household income level. This information is required of all applicants.
Does your mother(Adoptive) have a Bachelors degree (4 year college degree)?

YesNo
Does your father(Adoptive) have a Bachelors degree (4 year college degree)?

YesNo
The Talent Search Program is federally funded; therefore, we must document your family's income for the purpose of determining your eligibility status.

Please check below the source(s) of your family income and range of your total taxable family income. "Taxable income" is the amount you earned after exemptions and deductions are figured. If you filed an income tax form, utilize the figure shown on Line 15 on your 1040 form.
What is your family's taxable income in the past year? This information is on line 15 for 1040.*
Please put 0 if your family had $0 taxable income in the past year.
Does your family have any of the following?

Free/ Reduced LunchTANFPublic HousingFood StampsMedical CardUnemployment

Please complete the following chart for all individuals living in the household. (include yourself)

How many individuals are in your family?
(Please include applicant in the count)

Acknowledgements
I certify that the information on the application is correct and true to the best of my knowledge. I hereby authorize the Educational Talent Search staff to secure financial (also includes free/reduced lunch information) and academic information necessary to monitor student progress and determine student eligibility. I give permission for my child to participate in all activities, trips, and photos. ETS staff has permission to discuss my child’s financial situation with Shawnee Community College Financial Aid Officers and supply college personnel with their name and address for the express purpose of providing information to you about college. I further give permission for my child to receive all necessary medical attention if the need arises; such need shall be at the discretion of the medical provider on duty and/or the Educational Talent Search employee supervising or coordinating the activity or trip.
Student's Signature*

Clear
Student's Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Parent's/Guardian's Signature*

Clear
Parent's/Guardian's Name*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Educational Talent Search
Shawnee Community College
8364 Shawnee College Rd.
Ullin IL, 62992
618-634-3374
www.shawneeecc.edu/talent_search