Southeastern Oklahoma State University-TS-2021 Application Form

SOUTHEASTERN TALENT SEARCH EDUCATIONAL PROGRAM SERVICES
Student Application & Parent/Student Medical Information Waiver

Southeastern Oklahoma State University
425 W University Boulevard
Durant, Oklahoma 74701-3347
PHONE: 580-745-2883 FAX: 580-745-7453
www.se.edu/talentsearch

Student Information
Date*

MonthDayYear
mm-dd-yyyy
Birth Date*

MonthDayYear
mm-dd-yyyy
Age*
Name*

First NameLast Name
Student Phone Number*
(999)999-9999
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Phone Number*
(999)999-9999
School*
Grade*
Email*
example@example.com
Gender*

MaleFemale
Do you have a disability? (Physical, Learning, IEP)*

YesNo
If yes, please explain

Ethnic Origin
Ethnicity/Race (you may check more than one)*

American IndianAfrican AmericanAsianCaucasian(White)HispanicOther
If Indian, Tribe
Do you have a CDIB card?*

YesNo

Parent/Student Medical Information/Waiver
Student Data
Social Security Number*
999-99-9999
Name*

First NameLast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*

MF
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Name*

First NameLast Name
Phone*
(999)999-9999
Parent/Guardian's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency/Medical Information
Physician's Name*

First NameLast Name
Phone*
(999)999-9999
Date of last tetanus shot*

MonthDayYear
mm-dd-yyyy
List any drug allergies*
Any physical condition such as diabetes, epilepsy, asthma, etc.*
List any medication or medical treatment you are taking*
Medical Insurance
Insured's Name*

First NameLast Name
Policy No.*
Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Name

First NameLast Name
Policy No.
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IN CASE OF MEDICAL OR SURGICAL EMERGENCY, I hereby give permission for the administration of first aid by Talent Search Representative or health official, for treatment by authorized physician, or for hospitalization. I release the Talent Search Staff and SE from all liability for sickness, injury or accidents occurring during my child’s participation in Early Intervention Component activities. I understand that I will be contacted in the event that my immediate attention is required.
In addition,*

I give my permission for the Talent Search Staff to give my son/daughter a Tylenol for a headache.
IN CONSIDERATION for my child, receiving permission to participate in the Southeastern Talent search Educational Program Services (STEPS), I hereby RELEASE, WAIVE, and DISCHARGE Southeastern, The Board of Regents of the State of Oklahoma, the State of Oklahoma, their officers, servants, agents, or employees, the STEPS programs and its staff (hereinafter referred to as RELEASES) from any and all liability, claims, demands, actions and causes of action sustained by my child, or to any property belonging to my child, while participating in the STEPS program, or while in, on, upon, or traveling to and from any program activity where it is being conducted.
I FURTHER hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASES from any loss, liability, damage or costs that they may incur due to my child's participation in said activity.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Phone Number (Day)*
(999)999-9999
Phone Number (Night)*
(999)999-9999
Other persons who may be contacted in case of emergency if I cannot be reached
Name*

First NameLast Name
Relationship to student*
Phone*
(999)999-9999
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Relationship to student
Phone
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

AUTHORIZATION FOR THE RELEASE OF STUDENT INFORMATION, TRAVEL, ANDPUBLICATION
AUTHORIZATION FOR THE RELEASE OF STUDENT INFORMATION, TRAVEL, AND PUBLICATION

I hereby authorize the high school at which my child is attending to release necessary copies of report cards, transcripts, test scores, immunization records, individualized education plans, verification of free/ reduced lunch and proof of graduation for the execution of academic enrichment and college admission preparation of my child such as grade checks, transcripts, test scores, immunization records, individualized education plans, verification of free/reduced lunch and proof of graduation for my child {main_name}.

I authorize the SE Talent Search Program to provide transportation services for my {main_name}. I hereby release SE Talent Search from any responsibility for any criminal act of malice, vandalism, theft and other unlawful behavior during his/her trips sponsored by the SE Talent Search Program.

By signing below, I give permission to the Southeastern Oklahoma State University’s Talent Search Program to display photos of my child on the SE Talent Search web site, social media outlets, newsletters, and other publicity materials. If you wish to have your student’s name and/or pictures withheld from being displayed please check this box.
I wish to have my student's name and/or pictures withheld from being displayed.*

YesNo
SE Talent Search is a federally funded program developed to provide educational opportunities for your student. In order to justify the use of federal monies, we must have full participation from parent and student.

In order for your son/daughter to participate in SE Talent Search, we must have your commitment and involvement to encourage your son/daughter to follow the SE Talent Search guidelines:
1. Attends activities/meetings unless a valid reason is given to the SE Talent Search staff.
2. See that he/she returns all RSVP’s by the date due indicating whether he/she will or will not attend.
3. If my son/daughter makes a commitment to attend an event and a conflict arises, I will let the SE Talent Search know immediately.
4. Keep track of my student’s academic progress and encourage him/her to keep grades at passing level, and if my son/daughter is failing, I will see that he/she attends tutoring sessions.
5. I understand that my son/daughter will resign from the SE Talent Search program for any illegal drug or alcohol use,
  or if he/she does not perform according to federal academic guidelines.
6. I give permission for my son/daughter to make educational, cultural, and recreational trips with SE Talent Search.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy