I certify that this application has been filled out completely and correctly to the best of my knowledge. I understand that I am required to keep a grade point average of at least 2.30 to remain in the program and to attend special activities such as field trips. I further understand that I must attend at least 2 ETS activities each program year (September 1 to August 31). I understand that if I attend a school other than an Akron public school, I must give ETS a copy of each report card and must maintain contact with my appointed Educational Specialist.

The University of Akron's Educational Talent Search project is federally funded, therefore, we must document your family's income for the purpose of determining your eligibility status.

Please check below the source(s) of your family income and the range of your total taxable family income. "Taxable income" is the amount you earned after exemptions and deductions are figured. If you filed an income tax form, use the Taxable Income of your 1040 EZ form. Please ask us if it is not clear what to fill in.

I certify that the income information as stated above is accurate and that this application has been filled out completely and correctly to the best of my knowledge. I understand that my student is required to keep a grade point average of at least 2.30 to remain in the program and to attend special activities such as field trips. I further understand that he/she must attend at least 2 ETS activities each program year (September 1 to August 31). I understand that if he/she attends a school other than an Akron public school, we must give ETS a copy of each report card and must maintain contact with our appointed Educational Specialist.

I hereby grant permission for the officials at my child's school to release copies of his/her permanent record, test scores, and grades to the Educational Talent Search Program at The University of Akron. Permission for the release of my child's school records will remain in effect until he/she is no longer a program participant or until he/she has graduated from high school.

Confidentiality of school records is protected by state and federal law. Any person/facility receiving authorized information may not make further disclosure without the written consent of the person to whom it pertains.

I understand that I can revoke this authorization at any time by providing written notice to the person/facility who I designated to release the information. I understand that any information released prior to revocation cannot be retrieved and neither person/facility receiving the information will be held responsible for such.

I hereby release Educational Talent Search, The University of Akron, and its employees and agents from all legal responsibilities of liabilities that may arise from this act.

The University of Akron Educational Talent Search (ETS) is partnering with the Akron Public Schools and Summit Education Initiative to promote the success and academic achievement of students in Summit County. Summit Education Initiative (SEI) is a nonprofit organization located in Akron, Ohio, dedicated to increasing educational attainment in Summit County, Ohio. In this work, SEI provides secure data access between Akron Public Schools and The University of Akron Educational Talent Search (ETS).

The Family Education Rights and Privacy Act (FERPA) protects students and parents by prohibiting most third parties from accessing student records, information, or data without clear permission from a parent or guardian if the student is under 18.

This form requests your consent to allow The University of Akron Educational Talent Search (ETS) to share the name, grade level, date of birth, student ID number and school of your child with SEI. Additionally, you are consenting to allow SEI to provide The University of Akron Educational Talent Search (ETS) access to your child's Akron Public Schools data, including test scores, grades, attendance records, and results of student surveys. Your consent allows data to be shared in two directions: from The University of Akron Educational Talent Search (ETS) to Akron Public Schools; and from Akron Public Schools to The University of Akron Educational Talent Search (ETS). SEI is acting on behalf of both parties to match the information provided by The University of Akron Educational Talent Search (ETS) with your child's school information, and to conduct research to determine the effectiveness of programs on student success and achievement.

Accessing or sharing records, information, or data will be done to promote and support your student's academic success and achievement, and to evaluate services being offered. No records, information, or data will be used for any other purposes, and will not be shared with any party other than those listed in this release.

Parent/Guardian Consent

I give consent for Summit Education Initiative to provide secure sharing of my child's personally-identifiable information between The University of Akron Educational Talent Search (ETS) and the Akron Public Schools. I understand the following information will be shared:

• Student Name, grade level and date of birth, student ID number
• School district name nad school building name
• Course grades and Grade Point Average
• National and state test results
• Attendance records (classroom and school absence totals, both excused and unexcused)
• Results of surveys administered at the building and/or district level

I understand that my child's information will only be shared between Summit Education Initiative, The University of Akron Educational Talent Search (ETS) and Akron Public Schools, and that this consent may be terminated at any time by my written request as the parent/guardian listed below. It is also my understanding that this consent will last until my child is 18 years old, unless it is revoked by me in writing, or unless my child is no longer affiliated with The University of Akron Educational Talent Search (ETS) or registered as a student in Akron Public Schools. As a parent or guardian, I have the right to revoke consent at any time. I also have the right to obtain copies of any information about my child that is shared because of this form.

This page is to be filled out by a parent or guardian on every child attending The University of Akron Summer Programs. To avoid confusion: ONLY ONE CHILD PER FORM.

If neither the parents nor guardians are available in an emergency notify:

Medical Insurance Information - Please complete all sections

Statement of Wellness for Participation

I, {parentguardianName32}, do hereby verify that my child, {main_name}, to the best of my knowledge is free from contagious disease, is fully immunized, and is able to participate fully in the summer programs.

Permission to Administer Emergency Treatment

In the case of a medical emergency and the event that the parent/guardians named on this form cannot be reached, I hereby give my permission for emergency treatment to be administered to my child, named above. I agree to assume financial responsibility for all expenses associated with the emergency care and/or transportation for said child. Additionally, I agree not to hold University of Akron Summer Programs, its officers, or its employees, liable for any injury or losses related to the emergency care my child receives.

Permission for Over the Counter Medications

I authorize the school nurse, or athletic trainer to administer the following over the counter medications at their discretion.

I understand that there are risks associated with taking any medication, and I agree not to hold University of Akron, its officers or its employees liable for any injury to my child related to the administration of any medication listed above.

As the parent/guardian of {main_name}

I authorize and permit my student to participate in field trips, activities, and events offered by the University of Akron Educational Talent Search program. Further, I warrant and represent that:

1. My student is in good health and physically fit to participate in ETS field trips, activities, and events. There are no medical reasons, except as noted on the Medical Emergency Treatment Consent Form located in the previous section, that preclude or limit my student's participation in any field trips, activities, or events.
2. I know The University of Akron does not have medical insurance. Should my student need medical attention, I have adequate insurance to meet this need.
3. I am aware of the clothing needs for field trips, activities, and events, and I will insure that my student is appropriately dressed.
4. I am aware that in any field trip, activity or event there are certain risks. I have explained to my student the appropriate behavior expected for participation in field trips, activities, and events and that my student must obey all rules, regulations and instructions given or applicable for the field trip, activity, or event in which he/she is a participant.
5. I agree that The University of Akron and anyone associated with it will not be liable for:
   1. any loss, injury or death related to the field trip, activity, or event except that caused by an employee as a result of his or her gross negligence or intentional tort; or
   2. any loss, injury or death that occurs as a result of another student's action or failure to act, or those of a nonparticipant's actions or failure to act related to this field trip, activity, or event.
6. Further, I agree to indemnify and hold harmless The University of Akron and its Board of Trustees, officers, faculty and staff, from any claims whatsoever occasioned in any of these situations for which I have agreed that The University of Akron shall not be liable.

I have read this Release form. I understand the form and all words used in the form.

Internet Acceptable Use Release

I understand my child has applied to The University of Akron (UA) for computer access and my permission is needed before the account can be activated.

I further understand access to computers and computer networks open the door to a wide range of educational and entertainment material on the Internet, including some adult material. I acknowledge that UA cannot screen the material on the Internet.

By signing below, I acknowledge having read the statement above and, agreeing to these terms and conditions, give my permission for the University to give the above-named child access to University computers and computer networks, and to all of the material accessible by those means. I agree to take responsibility for my child's use of the computers and networks.