Northern Arizona University-TS-Application Form

The NAU Talent Search Program is funded by the U.S. Department of Education. The program is designed to encourage and prepare participants to attend college. All information shared with the NAU Talent Search program is STRICTLY CONFIDENTIAL and is used solely for placement in the Talent Search Program.

If you have any question please feel free to contact us at 928-523-3305, ets@nau.edu, visit our website www.nau.edu/ets, or address any mail to PO Box 5907 Flagstaff, AZ 86011

ELIGIBILITY/ INCOME INFORMATION
Living Status:

Live at homeResident DormitoryOther (please explain)
Household Status:

Both ParentsFoster (Ward of State)Single ParentExtended (Grandparents, Aunts, etc.)Other (please explain)
Number of people in your Household (including yourself):

Please list all the people living in your Household (include students away at school):

	Name:	Highest Grade or Degree Completed:
1
2
3
4
5
6
7
8
9
10

Check your head of household NET INCOME on the appropriate line below. (This is your take home income amount, AFTER TAXES)

$0 - $16,335$16,336 –$22,064$22,065 - $27,794$27,795– $33,524$33,525 – $39,254$39,255- $44,984$44,985 – $50,714$50,715- $56,445Other

If you did not file an income tax return, please list the money you received from any of the following sources:

	Amount
Aid to Families w/dependant Children (AFDC)
Unemployment
Ward of State-Foster Child
Public Assistance (GA, Welfare, Medicaid)
Disability
Social Security Benefits
Workman’s Compensation
Retirement
Free/Reduced Lunch
Other (please specify below)

STUDENT SELF-ANALYSIS
Please check any difficulties that may prevent you from completing this school year:

NoneransportationAbsenteeism/truancyPregnancyAcademicsFinancialPeer ProblemsSubstance AbuseHealthFamilyPersonal ProblemsOther
List careers you are interested in:
Check the area(s) in which you would like assistance:

TutoringPersonal CounselingCareer AssessmentGED/HS EquivalencyCollege Admission TestingCareer CounselingFinancial Aid InformationPost Secondary EducationInterview SkillsAcademic CounselingCourse SelectionCollege AdvisementStudy SkillsMentoringScholarship InformationCollege Visitation/Orientation
Please indicate the workshops you are interested in attending:

Career Planning InformationCollege 101ACT/SAT PreparationDecision MakingAlcohol & Substance AbuseImproving Study SkillsPlanned Parenthood InformationHow to Like/Love YourselfGoal Setting (career, academic)Life After High SchoolHow to Survive in the CityWho am I, Who are You?Financial Aid/ScholarshipsFun, Without Getting in TroubleStress ManagementManaging Your $$Balancing Your LifeLeadership SkillsJob CorpsIs a Vocational Trade for Me?Other topics
If Talent Search hosted workshops, would your parent or guardian participate?

YesNo
Please list specific course(s) in which you need tutoring:

Please rate yourself in the areas below:

	Poor	Below Average	Average	Above Average	Excellent
Writing Ability
Science Ability
Math Ability
Reading Ability
Egnlish Ability
Study Skills
Self-Esteem
Vocational Skills
Motivation
Time Management
Extracurricular Activities

Photo Release Information

I hereby release Northern Arizona University, its legal representative and all persons acting under its permission or authority, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in taking of said picture(s) or video or in any subsequent processing thereof, as well as any publication thereof. I declare that
my child is not of legal age and I have every right to contract in my child’s name, as their parent or legal guardian, in the above regard.
Date

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian

First NameLast Name
Parent/Legal Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
Student/Participant

First NameLast Name
Student/Participant

Clear