University Of Texas-San Antonio-San Antonio-TS-Application Form

University of Texas-San Antonio

TRIO Talent Search
Si desea ver el formulario en español, cambie el idioma en la esquina superior derecha.
Dear Applicant,

Thank you for your interest in the TRIO Talent Search at The University of Texas-San Antonio. Talent Search (TS) is a TRIO program that identifies and assists individuals from underrepresented backgrounds who have the potential to succeed in higher education. ETS at UTSA currently serves students at middle schools and high schools in San Antonio. The program provides FREE academic, career, and financial counseling to support high school graduation and encourage postsecondary degree completion for participants, most of whom will be the first in their families to complete a bachelor’s degree. Talent Search is grant-funded to serve a combined total of 500 students in San Antonio. Talent Search Program is a year-round program.

There is a summer program offered first to students who have participated in the year-round portion. The summer program is designed to simulate the experience of attending college. The summer program focuses on academics and enrichment activities.

Below you will find instructions for completing the application process. Applications are accepted and reviewed year-round, but students are only accepted if space permits.

All of the information contained in this application will remain confidential by the UTSA Talent Search staff in determining the eligibility of a student. Once your application is received, you will be notified of your application status. We look forward to you being a part of our family!

The University of Texas at San Antonio Office
1.302 Buena Vista Bldg.
UTSA Downtown Campus San Antonio, TX 78207

Genesis Cordia
Lead Retention Specialist (Holmes and Ross)
210-404-8938 (call or text)
genesis.cordia@utsa.edu

Anthony Rodriguez
Lead Retention Specialist (John Jay and Rayburn)
210-737-4502 (Call or Text)
Anthony.rodriguez2@utsa.edu

Jay Smiley
TRIO Project Director
Email: jay.smiley@utsa.edu

Important Parent Note: ETS is a free, academic support program provided through funding from the U.S. Department of Education. Students will have participation objectives, but the program will work to balance other high school commitments such as sports team involvements, other academic interests, and community service.

Parent/Guardian Demographic Information
Must be completeted by a Parent or Guardian:
Parent/Guardian Information:

Parent/Guardian 1
Parent/Guardian 1 Name*

Legal First NameLegal Last Name
Relationship to Student *
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian 1 Cell Phone*
(999)999-9999
Are you the Primary Contact?*

YesNo
Parent/Guardian 1 Email*
example@example.com
Occupation*
Work Phone*
(999)999-9999
Home Phone Number*
(999)999-9999
Parent/Guardian 2 – Complete if Applicable
Parent/Guardian 2 Name:

Legal First NameLegal Last Name
Relationship to Student
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian 2 Cell Phone
(999)999-9999
Are you the Primary Contact?

YesNo
Parent/Guardian 2 Email:
example@example.com
Occupation*
Work Phone*
(999)999-9999
Home Phone Number*
(999)999-9999
ALTERNATE EMERGENCY CONTACT #1
Alternate's Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Home Phone*
(999)999-9999
Cell Phone*
(999)999-9999
Relationship to Student*
ALTERNATE EMERGENCY CONTACT #2
Alternate's Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Home Phone*
(999)999-9999
Cell Phone*
(999)999-9999
Relationship to Student*

Parent Financial Statement & Verification of First-Generation and Income Status
**PLEASE HAVE PARENT FILL OUT INFORMATION BELOW
Student’s Name:*

First NameLast Name
Is the student is an orphan, in foster care, or a ward of the court?*

YESNO
*If yes, please skip the Statement of Income and First-Generation Verification. Please sign the certifying statement.
Statement of Income:
Parent/Guardian 1 Name*

First NameLast Name
Did you (the child's parent(s) or legal guardian(s) file taxes last year?*

YESNO
Tax Year*
Please provide your most recent total household taxable income (include both parents/guardians if applicable).*
*Located on 1040 form: Line 15
Family Size*
Number of people in the household
Did you receive any of the following assistance in 2023? (check all that apply):

Supplemental Security IncomeSection 8SNAPTANFOther
Does the student regularly reside with and receive support from this parent/guardian?*

YESNO
Parent/Guardian 2 Name:

First NameLast Name
Did you (the child's parent or legal guardian) file taxes last year?

YESNO
Tax Year
If yes, please provide Taxable Income
1040: line 15
Family Size
Number of people in the household
Did you receive any of the following assistance in 2023? (check all that apply):

Supplemental Security IncomeSection 8SNAPTANF
Does the student regularly reside with and receive support from this parent/guardian?

YESNO
First-Generation Verification:
Has either natural or adoptive parent earned a Bachelor's (4-yr) Degree?*

YESNO
If yes, please indicate which parent

MOTHERFATHERBOTH
With whom does the child live?*

MOTHERFATHERBOTHN/A
1.) Number of Exemptions claimed (line 6d of IRS Form 1040 or 1040SR) *
OR Did not file 2020 federal income taxes. My family’s total income from the last year was*
OR*

My family had no taxable income during the last calendar year.
Did you receive:*

Soc. Sec./SSIAFDCChild SupportFree LunchFood StampsOther
I certify the above information is accurate and true to the best of my knowledge. I understand that Talent Search is a federally funded program and the information reported above is required by the United States Department of Education to verify my child’s eligibility for program services. I acknowledge that information found to be false will jeopardize my participation in the Talent Search Project.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent /Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
1) Are you a citizen or national of the U.S. or do you meet the residency requirements for federal student financial assistance?*

YesNo
3) Do you have a documented physical or learning disability?*

YesNoPrefer Not to Answer
*If yes, is the documentation on file with the Counselor’s Office?*

YesNo
4) Did your parent or guardian GRADUATE from a four-year college/university?
Father*

YesNo
If yes, please list the name of the college/university and degree received:*
Initials*
Mother*

YesNo
If yes, please list the name of the college/university and degree received:*
Initials*
Student Name:*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Is the student covered by any medical insurance?*

YesNo
If Yes, please complete the following:
Name of Insurance Company*
Insurance Policy Number*
Name of Family Physician:*
Office Telephone:*
(999)999-9999
As the Parent I hereby authorize over the counter medication (ibuprofen, Pepto Bismol, etc) to be dispensed to my child.*

YesNo

Please list any personal or family medical history that may be of importance to our records, including allergies and physician prescribed medicine that student is currently taking:*

	List Medication/Medical History	Allergies	Allergic Reaction
1
2
3
4

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.
Parent/Legal Guardian’s Signature:*

Clear
Date*

MonthDayYear
Date
Person to call in case of emergency:*
Phone to call in case of emergency:*
(999)999-9999

Photo Release
PHOTO RELEASE
I, ____________________, 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. I have read the foregoing and fully understand its contents. This release shall be binding on me and my heirs, legal representatives and assigns. *
Student Name
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name:*

First NameLast Name
Parent Signature:*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Certification/Release of Information
CERTIFICATION/RELEASE OF INFORMATION

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, 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, and staff for the purpose of coordinating academic and personal support services.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
** 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.

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.

Talent Search is a federally funded program by the U.S. Department of Education in cooperation with The University of Texas at San Antonio.

University of Texas-San Antonio