Western Kentucky University-TS 3-Application Form

WKU Educational Talent Search
Application
- (Your Social Security number is required to process this application).
- 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
- Student Home Phone
  (999)999-9999
- Email*
  example@example.com
- Sex*
  
  MaleFemale
- Social Security Number
  999-99-9999
- Date of Birth*
  
  MonthDayYear
  mm-dd-yyyy
- Are you a U.S. Citizen?*
  
  YesNo, but I am a Permanent ResidentNo, I am neither a U.S. Citizen nor Permanent Resident
- If a Permanent Resident, provide Permanent Residency number
- Current School*
- Current Grade*
- How did you learn about the ETS program?
  
  School Presentation/ETS Academic CoordinatorSchool Counselor/TeacherFriend/ETS ParticipantOther
- Are you currently participating in any other college preparation programs? (i.e. Upward Bound, GEAR UP, etc.)*
  
  YesNo
- If yes, please list the program
- What do you plan to do after you graduate from high school?
  
  WorkCommunity College/Jr. College4-year College or UniversityMilitaryTrade/Vocational SchoolOther
- Please check which services/activities you feel would help you the most as you prepare for college.
  
  TutoringAcademic AdvisingCollege Exam PreparationsScholarship/Financial Aid InfoFinance/Money ManagementCollege Admissions AssistanceCareer InformationCommunication SkillsStudy SkillsCollege VisitsCharacter DevelopmentLeadership DevelopmentCultural Awareness & DiversityDecision MakingConflict Resolution
- If accepted into the Educational Talent Search Program, I agree to meet with my ETS Coordinator, attend meetings, do my best academically and prepare to enter postsecondary education after high school.
- Student Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy
- Educational Talent Search | Western Kentucky University
  1906 College Heights Blvd. #11098 | Bowling Green, KY 42101-1098
  100 Jones-Jaggers Hall | www.wku.edu/ets
  Phone: 270-745-4737 | Fax: 270.745.2031
  Educational Talent Search, a TRIO program, is funded by the U.S. Department of Education.
- 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*
  
  12345678910Other
- 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*
  
  MotherFatherFoster ParentLegal GuardianStepparentOther
- 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*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy