California State University-Fresno-Porterville-TS-Application

Student Application

Student Information
Name*

First NameLast Name
Social Security #*
999-99-9999
Mailing Address / PO Box*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
mm-dd-yyyy
Place of Birth*
Gender

MaleFemale
Home Phone*
(999)999-9999
Mom Cell
(999)999-9999
Dad Cell
(999)999-9999
Student Cell
(999)999-9999
Student Email*
example@example.com
Student School Email*
example@mypusd.org

School and Grade Level
High School*
Grade*

8/99101112

What two careers are you interested in*

	Career Name
1
2

Residency Status*

United States CitizenPermanent Legal Resident
If Permanent Legal Resident, please submit a Copy of Residency Card

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Additional Information
Check all that apply to student

DisabledTeenage ParentMigrant StudentSpecial EdFoster ChildESL

Parent/Family Information
Total Number in Household*
This student lives with*

FatherMotherStepfatherStepmotherFoster Parent(s)Court Order Legal Guardian (Proof Required)
Court Order Legal Guardian Proof

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Father (Biological or Adoptive)
Name

First NameMiddle NameLast Name
Occupation/Career
Did he receive a university degree from a four-year college in the USA?*

YesNo
If so, what college?
Mother (Biological or Adoptive)
Name

First NameMiddle NameLast Name
Occupation/Career
Did she receive a university degree from a four-year college in the USA?*

YesNo
If so, what college?

Refer a sibling or friend in grades 8-11th

	Name	School	Grade
1
2

Parent Family Income
Please provide your family's previous year income information below.
# of dependents*
Taxable Income*

$0-$21,870$21,871-$29,580$29,581-$37,290$37,291-$45,000$45,001-$52,710$52,711-$60,420$60,421-$68,130$68,131-$75,840$75,841 or more
Attention Parent or Guardian

The Educational Talent Search Program office will not process this application without Parent Income. Please make sure Parent Income information is complete before you submit. Please contact our office if you have any questions. Hablamos Español (559) 791-2293
Did you file income tax forms this past year?*

YesNo (if so, please check one of the below and indicate the Annual Benefited Amount)

Check all that apply

	Annual Benefited Amount
Social Security
Disability
Foster Child
Public Assistance
Unemployment Insurance
Other (Please explain below)

Other
I/We, the undersigned, declare under penalty of perjury that all the income reported on this application is true, complete, and accurate to the best of my knowledge.
Parent/Legal Guardian Signature*

Clear
Relationship to Applicant*
Date

MonthDayYear
mm-dd-yyyy
This information is protected by the Privacy Act. No one may see the information unless they work with, or for the Educational Talent Search Program, or are specifically authorized to see it. The information is necessary to determine if the applicant is eligible to participate in the Educational Talent Search Program.
Medical Release: Should my student require medical attention while participating in Educational Talent Search Program (ETS) activities and I cannot be contacted, I give my consent to medical examination and treatment deemed necessary by the
attending medical professional.

Permission to Access School Records: As a requirement through the Department of Education and our grant, ETS at California State University, Fresno Foundation must track students as they progress through post-secondary education. I hereby give ETS Staff consent in collecting high school records and data following admissions to post-secondary institutions such as but not limited to: transcripts, assessment scores, class schedule, diploma/degree/certification, projected graduation date, grade point average and National Student Clearinghouse inquiries. I authorize ETS to obtain records related to my child's application for college admission and acceptance status, financial aid application (FAFSA), and award letters at any colleges and universities. This information will be used as a component for its reporting to the US Department of Education in its Annual Performance Report and as statistical data provide to California State University, Fresno, Foundation.

Media Release: I hereby give permission to the ETS Program Staff to photograph and/ or take video of my child for promotional purposes and/ or file records related to the ETS Program and/or statements to be used by ETS for promotion, publicity, or instructional purposes.

Remind App: I give my consent for ETS Program Staff to send my student notifications through the Remind app. The Remind app is used by ETS Program Staff to communicate with students for any updates or deadlines approaching at the time of their participation with the program.

By signing my name on the signature line, I/We declare under penalty or perjury that all the information reported on this application is true, complete and accurate to the best of my knowledge.
Student's Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian's Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy