Indian River State College-TS

INDIAN RIVER STATE COLLEGE
EDUCATIONAL TALENT SEARCH

PARTICIPANT APPLICATION

Information on this form is confidential.

Part III: FAMILY/INCOME INFORMATION
With Whom Does The Applicant/Student Live? Check all that apply

FatherMotherStepfatherStepmotherFoster Parent(s)Court Ordered Legal GuardianOther
Parent/Guardian #1
Name

First NameLast Name
Relation

MotherFatherStep-parentOther
Occupation
Contact Number: Cell
(999)999-9999
Work
(999)999-9999
Email
example@example.com
1st language
Does parent/guardian speak English?

YesNo
Highest level of education completed in USA

Did NOT graduate from high schoolHS Diploma/GEDAssociateBachelorMasterDoctorate
Parent/Guardian #2
Name

First NameLast Name
Relation

MotherFatherStep-parentOther
Occupation
Contact Number: Cell
(999)999-9999
Work
(999)999-9999
Email
example@example.com
1st language
Does parent/guardian speak English?

YesNo
Highest level of education completed in USA

Did NOT graduate from high schoolHS Diploma/GEDAssociateBachelorMasterDoctorate
Which income tax form did the applicant's parent/legal guardian file last year?

10401040EZ1040A-OR- Parent(s)/Guardian(s) DID NOT file income tax forms this past year.
(Attach signed copy of last year’s tax return)

Browse Files

Cancelof
Taxable Income: $

-AND- Received the following (check all that apply): Indicate the Annual Benefited Amount below AND attach copy of documentation

	(check all that apply)	$
Social Security
Welfare/A.F.D.C
Disability
Unemployment Insurance
Foster Child
Food Stamps
Veteran’s Benefits
Other (please explain below)

Family size (total number of people living in the household or supported by parent/guardian)
I, the undersigned, declare under penalty of perjury that all the income reported on this application is true, complete, and accurate to the best of my knowledge.
Signature of Parent/Guardian

Clear
Relationship to applicant
Date

MonthDayYear
mm-dd-yyyy
This information is protected by the Privacy Act. No one may see the information unless they work with, or for the Educational Talent Search Program, or are specifically authorized to see it.
Notification of Social Security Number Collection and Usage

Indian River State College is in compliance with FL Statute 119.071(5) regarding the collection and usage of Social Security numbers. Copies of the IRSC Notification of Social Security Number Collection and Usage document can be obtained from Student Services at all IRSC campuses and at the IRSC website at www.irsc.edu

Part IV: MEDICAL CONSENT FORM
Dear Parent or Guardian:

The IRSC Health and Wellness Center provides student health care services under the supervision of a registered nurse. It is necessary for you to sign this form for your child to receive student health care if he/she is under the age of 18. Your signature below authorizes the appropriate treatment for your child, which may include:
1. First Aid Care
2. Treatment of health problems (stomachaches, earaches, headaches, cuts, sores, colds, coughs, ringworms, etc.)
3. Minor Emergency Care
Indicate any special needs your child may have
Your signature on the line below indicates your consent for treatment
Parent/Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
Sign below if you DO NOT want the health team to provide any services to your child.
Parent/Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
If you have any questions, contact the IRSC Health and Wellness Center at (772) 462-7825.

Part V: RELEASE & AUTHORIZATION
RECORDS RELEASE

I authorize the release of school records for the applicant’s file that may be requested by Educational Talent Search at Indian River State College. I understand that the U.S. Department of Education funds Educational Talent Search and will use these records to provide academic advisement and other services. I also understand that these records will be handled in a confidential manner and that they will be made available only to program staff and representatives from Federal and State Departments of Education.

This authorization release includes, but is not limited to, the following records:
- Official School Transcript
- Student History File with test scores
- Academic History with test scores
- Basic Skills Test Results
- Attendance Record for 6th-12th grades
- Student grades/progress reports
- Information concerning disciplinary actions
- Test Results (PSAT, SAT, ACT, TABE, PERT, FCAT if available)
Note: A photocopy of this record release form should be accepted as an original and the date of the application has no bearing when the Indian River State College Educational Talent Search Program requests the information.

MEDICAL AUTHORIZATION

If medical services are needed by my son/daughter while participating in the Educational Talent Search program or on field trips, I give my permission for my son/daughter to receive any medical services deemed necessary.

ACTIVITY AND FIELD TRIP AUTHORIZATION/RELEASE

As the parent/guardian of the applicant, I do willingly execute this release in consideration of the educational benefit to be derived by my child in participating in Educational Talent Search, a College sponsored activity. I hereby release from liability and hold the College harmless from any and all claims and causes of action which might be brought by my child for loss of property, personal injury or death sustained by my child arising out of travel or activity conducted by or under the control of the College. I understand that the term “College” as used herein shall include the employees, administrators, agents, and Board of Trustees of the College.

PHOTO RELEASE

I hereby grant Indian River State College Educational Talent Search permission to photograph/video my son/daughter and/or to use their likeness in photograph(s)/video in any and all of its publications and in any and all other media, whether now known or hereafter existing, controlled by Indian River State College Educational Talent Search, in perpetuity, and for other uses by the College or Program. I will make no monetary or other claim against Indian River State College Educational Talent Search for the use of the photograph(s)/video.

By signing, I hereby acknowledge and certify that the information contained in this application, and any attached supporting documentation provided, is true and correct.
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Applicant/Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy