Western Kentucky University-TS 1-Application Form

Educational Talent Search Application
Western Kentucky University

1906 College Heights Blvd. #11098, Bowling Green, KY 42101-1098
270-745-3757 | Fax: 270.745.2031 | www.wku.edu/ets
Educational Talent Search, a TRiO program, is funded by the U.S. Department of Education.
- Name*
  
  First NameMiddle InitialLast Name
- Prefer to be called
- Mailing Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Student Cell Phone
  (999)999-9999
- Can we text you?
  
  YesNo
- Student Home Phone
  (999)999-9999
- Email*
  example@example.com
- Sex*
  
  MaleFemale
- Date of Birth*
  
  MonthDayYear
  mm-dd-yyyy
- Social Security #
  999-99-9999
- U.S. Citizen?*
  
  YesNo
- If not a citizen, please provide Permanent Residency #
- Current School*
- Current Grade*
- Are you currently participating in any other college preparation programs? (i.e. Upward Bound, GEAR UP, etc.)
  
  YesNo
- If yes, please list the program
- Please check which services/activities you feel would help you the most as you prepare for college
  
  Personal OrganizationInterpersonal CommunicationDecision MakingCareer AssessmentPublic CommunicationCollege Admission RequirementsJob SeekingFinancial LiteracyAffording CollegeSetting GoalsStress ManagementTest AnxietyTest PreparationTime ManagementExploring College Majors
- Please help us learn more about you, a potential ETS participant, by answering the following questions.
- 1. What do you plan to do after you graduate from high school?
  
  WorkCommunity College4-year Institution (College or University)MilitaryTrade/Vocational SchoolOther
- 2. What career(s) are you interested in?
- If accepted into the Educational Talent Search Program, I agree to meet with my ETS Coordinator(s), attend meetings, do my best academically and prepare to enter postsecondary education after high school.
- Student Signature*
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- The Educational Talent Search program is funded to serve a percentage of students who meet the eligibility criteria of low income, first generation potential college student status meaning neither parent has a four-year college degree. In meeting this federal regulation we ask that you provide the following information used to determine eligibility. The information you provide is strictly confidential and used solely for the purpose of determining program eligibility.
- 1) Does either parent/guardian (natural or adoptive only; does not include step-parent) with whom the student lives have a four-year college degree (two-year associate degree should mark No)?*
  
  YesNo
- 2) Does anyone in the household QUALIFY for: (check all that apply)*
  
  Free School LunchWICReduced Price School LunchSupplemental Security IncomeFood StampsTemporary Assistance for Needy Families (TANF)NONE
- 3) Total number of people in household, including yourself*
  
  12345678910 or more
- 4) What was your household's taxable income last year? (NOTE: Do not use gross or net income, but taxable income which is typically much lower. Please review line 15 of the IRS 1040 to find this information). *
  
  No taxable income$1 - $23,940$23,941 - $32,460$32,461 - $40,980$40,981 - $49,500$49,501 - $58,020$58,021 - $66,540$66,541 - $75,060$75,061 - $83,580$83,581 or above
- Parent/Guardian Name*
  
  First NameLast Name
- Relation to Student*
- Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone*
  (999)999-9999
- Phone Type
  
  mobilehomework
- Phone
  (999)999-9999
- Phone Type
  
  mobilehomework
- Email Address
  example@example.com
- Please list an emergency contact (please provide someone other than primary caregiver)
- Emergency Contact Name*
  
  First NameLast Name
- Phone*
  (999)999-9999
- RELEASE OF RECORDS: The “Release of Records” is required for program participation. Records will be used to assess student needs, monitor progress, document eligibility, and for reporting purposes. This information is confidential and protected under the General Education Provision Act. ETS will not release any confidential information without your written consent.
  
  I hereby grant permission for the Educational Talent Search program at Western Kentucky University to have access to educational records of {main_name} including (but not limited to) grades, test scores, free/reduced price lunch eligibility, class schedules, postsecondary enrollment, and attendance for the duration of the student’s enrollment in the WKU Educational Talent Search Program.
  
  This also authorizes the postsecondary institutions to release to the WKU Educational Talent Search program copies of college academic enrollment and student aid award information.
- I authorize the use of my child’s photo by ETS for publicity and recruitment purposes for the duration of the student’s involvement in the ETS program.
  
  If you do NOT authorize ETS to use your child’s photo for media purposes, please check this box.
- I, the undersigned, confirm that all the information on this application is true to the best of my knowledge and feel that my child has shown potential for success in a postsecondary education program. My child has my support in this endeavor as he/she strives to be engaged in achieving success through ETS.
- Parent/Guardian Signature*
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy