University of Georgia-TS-Middle School Application Form

Educational Talent Search

Middle School Application
- Name*
  
  First NameMiddle NameLast Name
- School
- School*
- Date of Birth*
  
  MonthDayYear
  mm-dd-yyyy
- Age
- Gender*
  
  MaleFemale
- Ethnic Origin*
  
  African American/BlackAmerican Indian/Alaska NativeAsian/Pacific IslanderEuropean American/WhiteHispanicMore than one ethnic origin
- U.S. Citizen
  
  YesNo
- Visa Type/Number
- Free/Reduced lunch participant?
  
  YesNo
- Grade Point Average (GPA)
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Student Email Address*
  example@example.com
- Student Cell*
- Parent Cell
- Emergency Contact Person
- Relationship to you
- Emergency Telephone
- Student Signature *
  
  Clear
- You Must Complete All Information Below to Have Your Application Processed
  This information is strictly confidential and only for office use and funding purposes only
- Parent(s)/Guardian(s) Name(s)*
  
  First NameLast Name
- Parent(s)/Guardian(s) Name(s)*
  
  First NameLast Name
- Email*
  example@example.com
- Student lives with: (check one)*
  
  Both ParentsOne ParentParent/Step ParentFoster ParentLegal GuardianSpouseOther
- Number of family members in home? *
  (Brothers, Sisters, Parent(s), etc.)
- Select your family’s yearly gross income*
  
  $0-12,525$12,526 – 16,875$16,876 - $21,225$21,226 - $25,575$25,576 - $29,925$29,926 - $34,275$34,276 - $38, 625$38,626 - $42,975$42,976+
- Income Breakdown (If none, just enter 0)
- Social Security Income*
- AFDC or ADC *
- Child Support*
- Other Untaxed Income*
- Did either Parent GRADUATE from a four year college? *
  
  YesNo
- Name of College*
- I affirm that the information provided is complete and correct. Any deliberate falsification or omission of data supplied may result in denial of placement or dismissal from the Educational Talent Search Program.
- Parent/Guardian Signature*
  
  Clear
- Authorization
  for
  Release of Student’s Records, Information and
  Permission to Photograph/Video Student
  
  Privacy Act
  In accordance with the Family Educational Rights and Privacy Act, I understand that all information concerning my child and me is confidential and will not be revealed to anyone except Educational Talent Search Program Personnel.
  
  I, , Parent/Legal Guardian of ,(Please Print) (Please Print) authorize the Superintendent of Schools or her/his Designee(s) to release all records listed below to the following Agency and its Designee(s):
  Records:
  Attendance Data
  Psychological Education Reports Testing Data
  Health Records
  Grade Transcripts/Progress Reports Special Education Placement Data Student Clearinghouse
  Social Security Numbers
  
  University of Georgia TRIO Educational Talent Search 243 Milledge Hall Athens, Georgia 30602-1550
  (706) 542-7640 (Telephone)
  (706) 583-8246 (Fax)
  
  Student Schedules
  I further authorize the release of all information regarding my child’s educational, physical and social adjustments in school, as long as s/he participates in the Educational Talent Search Program.
  
  I also understand that prior to transfer, I may review and have all/any part of these records properly interpreted by making such request of the Principal or appropriate Board of Education Personnel.
- Permission to Photograph/Video Student: I agree to allow ETS and its constituents to photograph or digitally record my child for use in publication.*
  
  YesNo
- Student Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy
- Parent/Guardian Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy
- Program Coordinator Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy
- University of Georgia
  
  Middle School Contract
  
  As a student in University of Georgia’s Educational Talent Search (ETS) and as a major objective of ETS is to assist me with successful completion of middle and high school preparation, as recommended by my Program Coordinator, I agree to:
  1. Attend all scheduled ETS Sessions
  2. Follow my Participant Educational Plan (PEP).
  3. Give my Educational Program Coordinator all my Academic Status
  4. Reports and Report Cards.
  5. Participate fully in tutoring sessions designed to assist me in successfully completing middle school.
  6. Participate in career, cultural/educational activities, tours and workshops as offered.
  7. Encourage my parent(s) to attend, participate in and support ETS Parents’ activities as offered.
  8. Inform my Program Coordinator of my upcoming school placement at the end of each academic year.
    As parent(s) of an ETS student I/we agree to:
  1. Attend, participate in and support Parents’ activities designed to assist my/our child with successful completion of middle and high school preparation.
  
  Note: If a student is to fully gain from the services offered by ETS, it is imperative that s/he attends advisement and academic sessions, such as tutoring and school workshops in addition to cultural activities. All services offered by ETS are contingent upon one another. Failure to fulfill contract agreement could result in termination from ETS.
- *Student Initial Here to Acknowledge Reading of Contract*
- *Parent/Guardian Initial Here to Acknowledge Reading of Contract*
- University of Georgia Educational Talent Search Parent Association
  
  Parent/Guardian participation is critical to student success. As a member of our Parent Association, your assistance will help strengthen our program. If you are interested in serving please complete the following.
- Parent Name
  
  First NameLast Name
- Email
  example@example.com
- Phone
- Preferred method of contact (please select):
  
  PhoneEmail
- Are you interested in leadership role in Association (please select)):
  
  YesNoMaybe
- 1) Do you have any special needs*
  
  YesNo
- List:*
- 2) Have you or are you repeating a grade?*
  
  YesNo
- 3) Have you ever received in/out of school suspension?*
  
  YesNo
- If yes, please explain*
- 4) Do you need enrichment/tutoring in any subject?*
  
  YesNo
- List*
- 5) Do you need to develop/improve your study skills?*
  
  YesNo
- 6) Do you use time wisely?*
  
  YesNo
- 7) Are you dependable?*
  
  YesNo
- 8) How do you view the way you act, feel and think? Why?*
  
  NegativePositivePositive but Needs improvement
- 8) How do you view the way you act, feel and think? Why?*
- 9) Do you take responsibility for your actions?(school work, chores, money, etc.)*
  
  YesNo
- 10) Do you know how to handle conflicts without fighting?*
  
  YesNo
- Currently, what career do you wish to pursue? List: *
- 10) Do you know how to handle conflicts without fighting?*
  
  YesNo
- 12) Do you know facts about this career?*
  
  YesNo
- 13) Do you want to attend college/technical school?*
  
  YesNo
- 14) To prepare for college, are you knowledgeable of the academic classes that should be studied in high school?(8th graders only)*
  
  YesNo
- 15) Are you a member of/an officer in any school organization(s)?*
  
  YesNo
- List:*
- 16) Are you a member of/an officer in any school organization(s)?*
  
  Educational Talent SearchUpward BoundGear Up
- 17) Are you currently in foster care or homeless?*
  
  YesNo
- 18) How can ETS assist you in becoming a better student?*
- Are you on social media?
  
  FacebookInstagramTwitterOther

Educational Talent Search