Oklahoma State University-Oklahoma City-TS

TRIO Talent Search Participant Application

900 N. Portland Ave., Oklahoma City, OK 73107

405.945.9132

www.osuokc.edu/talentsearch

Student Information
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
SSN
999-99-9999
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Number*
(999)999-9999
Parent/Guardian Phone Number*
(999)999-9999
Student E-mail*
example@example.com
Sex

MaleFemale
School*
Grade*

Student Committment
In order to participate in the OSU-OKC Talent Search program I agree to:
- Attend school regularly, refrain from discipline/behavioral problems and strive to earn high grades in all classes
- Contact my ETS Coordinator/Counselor if there is a change in my class schedule, my home address or phone number, and/or if my family plans to move
- Seek help with academic or personal problems, if needed
- Take advantage of special program activities such as college visits, financial aid workshops, and cultural events
- Successfully be promoted to the next grade each year in the program
- Apply for financial aid during my senior year
- Graduate from high school and enroll in a post-secondary education institution after graduation
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Parent/Guardian Information
TRIO Talent Search is a federally funded grant from the Department of Education and must document student’s eligibility. All information requested is for these purposes and will be kept strictly confidential.
Mother's Education Level

High School Degree/GED or LowerAssociate's Degree (2-year college degree)Bachelor's Degree (4-year college degree)
Father's Education Level

High School Degree/GED or LowerAssociate's Degree (2-year college degree)Bachelor's Degree (4-year college degree)

Income Verification
Does your child qualify for free or reduced lunch prices at school?

YesNo
Annual Taxable Income is located on your tax forms: line 43 on the 1040, line 27 on the 1040A and line 6 on the 1040 EZ.
Family Size*
Annual Taxable Income*
For Families Who Were Not Required to File an IRS 1040 or 1040A Form:
Family Size*
Total earnings (GROSS INCOME) for the previous tax year*
Source of Income
By signing this form, I agree that all information contained on this application is true and correct to the best of my knowledge. I further agree to allow my child to participate in the OSU-OKC Talent Search program.
Parent Signature

Clear
Parent Printed Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy

Medical Consent and Field Trip Authorization
School Name
Grade
Name

First NameMiddle NameLast Name
SS#
999-99-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
mm-dd-yyyy
List any severe medical problems that we should know about (for example, chronic diseases, allergy to drugs, physical handicaps, etc.)?
Is your child on any medication?

YesNo
If yes, please list medications
At the present time, is he/she under medical care?

YesNo
If yes, for what?
If yes, what is the doctor's name, address, and telephone number?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
(999)999-9999
Parent's Name

First NameLast Name
Phone or Cell #
(999)999-9999
In case of emergency, the person to contact if the parent/guardian cannot be reached is
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
(999)999-9999
What relationship is this person to the student?
- I do hereby authorize the Talent Search staff to give permission for the performance of medical examinations and necessary treatments (including test, x-rays, medicine, etc.) as may be deemed necessary by the physician in attendance. This consent shall be in effect for the period of time that my son/daughter is enrolled as a student in Educational Talent Search. If any emergency arises requiring a major surgical procedure, the program will attempt to reach me and to be guided by my wishes. If I cannot be reached, I authorize the attending physician to act as medical judgment may dictate.
- I grant my son/daughter permission to participate in Talent Search sponsored activities and field trips. I understand that my son/daughter is expected to obey all rules and regulations of the Talent Search program. I also understand that failure to obey written or verbal rules and regulations will be sufficient reason for terminating my child from participation in Talent Search activities or field trips by sending them home.
- I hereby release and forever discharge Oklahoma State University–Oklahoma City and its staff members from all manner of claims and responsibility due to any risks encountered by my son/daughter.
I hereby authorize the OSU-OKC Talent Search Program to have access to my child’s permanent school records during the application process and throughout the period of their participation in the program. I also give permission for the use of my child’s name and /or photograph for editorial, promotional, recruitment or educational purposes.

OPT-OUT of photography publication
Parent/Guardian Signature

Clear
Date of Consent

MonthDayYear
mm-dd-yyyy

Student Needs Assessment
Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
School
Grade
This survey contains a number of statements about student needs. Please give your honest opinion of how the Talent Search Program can meet your needs. Your answers will be kept confidential.

Academic Needs

	Strong Need	Some Need	No Need
1. To learn how to complete and turn in my homework on time.
2. To get better grades in school.
3. To take test better and with less anxiety.
4. To organize my time, activities and responsibilities better.
5. To learn more about high school requirements for college.
6. To listen better in class and ask more questions.
7. To relate to and communicate better with my teachers.
8. To identify, set and evaluate goals for the future.

My academic goal is

Personal Needs

	Strong Need	Some Need	No Need
1. To better understand my parents and other adults.
2. To learn to deal with conflict in a positive manner.
3. To be more accepting of my physical appearance.
4. To learn how my self-esteem affects my behavior.
5. To learn how to get along better with members of the opposite sex.
6. To learn to accept people who are different from me.
7. To learn more about the use/abuse of drugs and alcohol.
8. To accept greater responsibility for my actions.

My personal goal is

Career and Postsecondary Needs

	Strong Need	Some Need	No Need
1. To explore a variety of career opportunities.
2. To learn more about job applications, resumes and interviews.
3. To learn more about the postsecondary admissions process
4. To prepare for exams like the ACT or SAT.
5. To visit more colleges.
6. To learn about college costs and how to pay for college.

Name a college, university or technology center you would like to visit.