Parent or Guardian 1

Did either of your parents or guardians you primarily live with GRADUATE (with a 4-year bachelor’s degree) from a 4-year college/university?

INCOME INFORMATION

Parent(s)/Guardian(s): Provide information from parent(s)/Guardian(s) IRS form 1040, 1040A or 1040EZ for the past calendar year

PARENT/GUARDIAN SIGNATURE REQUIRED

I verify that the eligibility information provided above is true and accurate to the best of my knowledge.

Which of the following services may be of interest and/or benefit to you? (Please check all that apply).

Academic Needs

Post-Graduation Plans

As the parent/guardian of the above named student, I hereby authorize the Executive Director and his/her authorized staff to furnish medical diagnostic and/or authorize the medical and/or surgical treatment of my child as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the child. The University of Texas at San Antonio and its officers, regents and employees shall not be liable in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise out of such diagnosis, treatment or surgery to the extent allowed by law, except as provided for through the group medical insurance plan if the student contracted for the same prior diagnosis, treatment or surgery.  Furthermore, the University does not assume any financial or other responsibility, but wishes to provide the best services possible in case of emergency.  

In case of sudden illness or accident, I consent to emergency treatment by the professional medical/nursing staff of the Student Health Services to my child.  In case of serious illness/accident I will be notified immediately, but if I cannot be reached, necessary interim emergency care may be provided by the Student Health Services professional Medical/Nursing staff or by a physician/nurse designated by them

I, {studentName}, hereby grant The University of Texas at San Antonio (“UTSA”) the absolute and irrevocable right and permission, to record my image, likeness and/or voice on a video, audio, photographic, digital, electronic or any other medium (“Recording”) in which I may be included with others, to copyright for same; to use, reuse, alter, edit and publish the same in whole or in part in any and all media including but not limited to use on the world wide web, now or hereafter, and for any purpose whatsoever that UTSA deems appropriate including but not limited to, exhibition, education, illustration, promotion, art, advertising and trade, and if appropriate, to use my name and pertinent education and/or biographical facts as UTSA chooses.

I hereby release and discharge UTSA, its governing board, officers, representatives, employees and agents from any and all claims and demands for compensation arising out of or in connection with the use of the Recording.

I hereby release and discharge UTSA, its governing board, officers, representatives, employees and agents from any and all claims and demands arising out of or in connection with the use of the Recording, including without limitation any and all claims for libel or invasion of privacy.

I am of full age and have the right to contract in my own name (OR, I am a minor and the signature of my parent/guardian indicates we have both read the foregoing and fully understand its contents). This release shall be binding on me and my heirs, legal representatives and assigns

I certify that the information I have provided on this application is, to the best of my knowledge, true and correct.  Furthermore, I understand that by applying for this program, I authorize the Educational Talent Search Program to obtain records or data pertinent to my participation from other sources (including, but not limited to, Principal/Counseling Office, Financial Aid, Student Disability Office, and Office of the Registrar), and to release information as required by law or the terms of the Educational Talent Search Grant, to the grant-funding agency of the federal government**.  I further authorize Educational Talent Search Staff to discuss issues related to my academic progress with other high school faculty, university faculty, Principal/Counseling Office, and staff for the purpose of coordinating academic and personal support services. SIGNATURE REQUIRED

** The University of Texas at San Antonio Educational Talent Search (ETS) is asking you to provide information which includes private information under state and federal law. ETS is asking for this private information so that we can process your application for your admission to our program. This information will be used to evaluate your application for admission to determine whether you are a suitable candidate for admission into our program. You are not legally required to provide the information ETS is requesting, and you may refuse to provide some or all of the information requested. However, ETS may not be able to consider your application if you do not provide sufficient information. With some exceptions, unless you consent to further release of private information, access to this information will be limited to the individuals involved in our admission process (including the Financial Aid, Student Disability Office, and Office of the Registrar) and the advisors and clerical personnel of the program. However, federal and state laws do authorize release of private information without your consent to: school officials who have legitimate educational interests in the information; the U.S. Dept. of Education for the purposes of program compliance, audit or evaluation; a court, grand jury, or state or federal agency, if the information is sought with a subpoena; appropriate persons in connection with an emergency, if necessary to protect your health or safety or the health or safety of others; if required by a court order, or permitted by other state or federal law.
PRIVACY ACT
In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Educational Talent Search Program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Educational Talent Search program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing the information on this form, including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to the National Student Clearinghouse or other UTSA department officials in the performance of their official duties.