FOR ETS SERVICES: (STUDENTS, YOU MUST FILL OUT THIS SECTION)

Mother/Guardian

Father/Guardian

Please complete all sections.  This should be completed by the parent/guardian with whom the student lives, or by the parent/guardian providing at least 50% of student’s financial support.

Additional information:

(To be completed Only if it applies to your current situation)

I certify that the above information is correct and true to the best of my knowledge.

I agree that Case Western Reserve University Educational Talent Search staff or volunteers associated with the college will not be held liable for any loss, injury, or death related to any field trip, activity or event. I authorize the ETS staff access to any and all academic records available from the school the student/applicant attends for the purpose of determining eligibility and providing educational services. I authorize and permit my child to participate in field trips, activities, and events sponsored and conducted by ETS. I grant permission for my child to access networked computer services such and the internet and email. I grant permission to the ETS office to take photos of my child for the purpose of promoting the Educational Talent Search program and Case Western Reserve University. In the event that my child is involved in a medical emergency, I authorize the ETS staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment etc.), if I am unable to be contacted or reached for verbal authorization.