Western Kentucky University-TS 3-Application Form

Talent Search is a federally-funded program from the U.S. Department of Education that serves a percentage of students who meet the eligibility criteria of low-income and first-generation potential college student, meaning neither parent currently 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.

Does either parent with whom the student lives have a four-year college degree?*

YesNo

(Note: For this question, “parent” refers to a natural or adoptive parent. If the student does not live with a natural or adoptive parent, please mark “no” for this question.)

Does anyone in the household qualify for (please check all that apply)

Free School LunchWICFood Stamps/SNAPTemporary Assistance for Needy Families (TANF) or Aid to Families with Dependent Children (AFDC)

Total number of people in household, including yourself*

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 11b of the IRS 1040 to find this information—indicate range below with a check mark)*

Parent/Guardian Name*

First NameLast Name

Relation to Student*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

(999)999-9999

Phone Type

MobileHomeWork

Alternate Phone Number

(999)999-9999

Phone Type

MobileHomeWork

Email Address

example@example.com

Please list an emergency contact (please provide someone other than the person listed above)

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*

Date*

mm-dd-yyyy