Elizabeth City State University-TS-Application Form

ELIZABETH CITY STATE UNIVERSITY

Application
Name:*

First NameMiddle NameLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
(999)999-9999
Birthdate:

MonthDayYear
mm-dd-yyyy
Age:
Race: (Check All That Apply)

Native AmericanAsian/Pacific IslanderAfrican AmericanHispanicNative HawaiianMore than one RaceCaucasian
Sex:

MaleFemale
Are you a United States citizen?

YesNo
Social Security Number (Last 4 digits only):
9999
Student Email Address:*
example@example.com
Student Cellphone Number:
(999)999-9999
Number in Household (Including Yourself):

List below (Including Yourself):

	Name	Relationship	Age
1
2
3
4
5

School Currently Attending
Grade
School Counselor’s Name
List the courses you are taking.
Attach a copy of your current grades to the completed application.

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Have you ever participated in a pre-college program similar to Talent Search (for example, Upward Bound, Gear Up, AVID)?

YesNo
If yes, please specify program and sponsoring school or organization.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

STUDENT QUESTIONAIRE
What are your plans after high school graduation? (Consider listing your goals)—attach additional pages, if needed):
Why is education important to you?
What difficulties are you having at this time? (For example, issues with course content, need tutoring in math, english, science, etc..).

PARENT INFORMATION

Please indicate the level of education completed. Type “Yes” only if you have completed the indicated degree. If you have started a degree, but not completed it, then Type “No.”

	Name	High School Diploma or GED?	2 Year College Degree?	4 Year College Degree?
Mother
Father
Legal Guardian
Legal Guardian

PARENT/GUARDIAN STATEMENT OF INCOME
The United States Department of Education requires that the Talent Search Program gather this data in order to determine student eligibility. Failure to provide the necessary supporting documents will prohibit your child from being considered for admission. The personal information you provide to the Talent Search Program will be kept confidential and is protected by the Privacy Act.
Annual Taxable Income Reported on Recent IRS Filing:
(if you were not required to file because you received benefits listed below, write in a “0”).
*Submit a copy of your most recently filed to 1040 or you can submit a signed written statement noting your taxable income for the 2021 year.

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Additional Questions:
Does your family receive non-taxable benefits?

YesNo
Social Security Benefits:

YesNo
Work First Cash Assistance:

YesNo
Veteran’s Benefits:

YesNo
Other (Specify)
Amount of Monthly Payment from sources listed above, if you checked “Yes.”
*Submit a copy of your monthly statement from a governmental source (must be an official statement on the organization’s letterhead).

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Please read each statement below and initial if you are in agreement with the information presented in each statement.

My initials (here) and my signature below confirms that the information reported in this section of the application regarding my income is accurate.
Initials
I confirm that the documentation I have provided is true and accurate.
Initials
Signature of Parent/Guardian:

Clear
Date

MonthDayYear
mm-dd-yyyy

PARENTAL CONSENT FOR ACTIVITY PARTICIPATION
UNCONDITIONAL AND FULL GENERAL RELEASE & COVENANT NOT TO SUE

This is to be read and signed by all participants using Elizabeth City State University (the “University”) facilities and/or participating in any program on the Elizabeth City State University sponsored program (the Talent Search Program) and their parent/guardian. PLEASE READ THIS CAREFULLY. IT AFFECTS CERTAIN RIGHTS YOU OR YOUR CHILD MAY HAVE IF YOU OR YOUR CHILD ARE INJURED OR OTHERWISE SUFFER DAMAGES PARTICIPATING IN THE PROGRAM. In return for Elizabeth City State University allowing me/my child to participate in the Talent Search Program and other good and valuable consideration, I agree, and state, on behalf of myself, my child, my heirs, assigns, executors and others, as follows:

1. This Release and Covenant Not to Sue contains the entire agreement between the University and myself/my child and supersedes any previous communications and/or agreement whether verbal or written, with respect to the subject matter of this Agreement.

2. I am competent to read and sign this "Unconditional and Full General Release and Covenant Not To Sue."

3. That I/my child understand/s that I/my child am/are participating in the Talent Search Program voluntarily and the Talent Search Program is not required by the University. I/My child understand that participation in the Talent Search Program is a privilege and that this privilege is a tangible benefit.

4. That I/my child am/are familiar with and will obey, any and all of the policies established by the University located at https://www.ecsu.edu/administration/legal/policymanual/index.html.

5. That I/my child understand/s and appreciate/s the inherent risks and dangers of participating in the Talent Search Program (e.g., any program physical or other activities) which could result in property damage and/or personal injury (e.g., sprains, broken bones, bruises, sunburn, heat related illness, or other serious injury, etc.), including death; and I/my child agree to accept all risks whether present or future, known or unknown, arising from or as a result of my participation in the Talent Search Program.

6. That I/my child WILL HOLD HARMLESS AND INDEMNIFY ELIZABETH CITY STATE UNIVERSITY, its officials, administrators, employees, all sponsors, affiliates, and individuals assisting in the Talent Search Program for any liability and all claims of damages, demands, and actions whatsoever in any manner resulting from my/ my child’s participation in the Talent Search Program.

7. That I/my child agree/s to assume all costs related with my/my child’s participation in the Talent Search Program, including but not limited to repair/replacement costs for property damage caused by me/my child, or medical expense.

8. That I understand and affirm that I/my child is/are healthy and reasonably fit in order to safely participate in the Talent Search Program.

9. That in the event that I/my child am/is rendered unable to communicate due to illness, accident, or emergency while participating in the Talent Search Program, I hereby give permission to a Physician selected by the Program's personnel to hospitalize, secure proper treatment for, and to take whatever medical actions are necessary to treat me/my child.

10. That I/my child have read and understand this "Unconditional and Full General Release and Covenant Not To Sue."

MEDICAL RELEASE

I understand that in the event that I/my child am/is rendered unable to communicate due to illness, accident, or emergency while participating in the Talent Search Program’s Academic Year and Summer

programs and activities, I hereby give permission to a Physician selected by the Program’s personnel to hospitalize, secure proper treatment for, and to take whatever medical actions are necessary to treat me/my child. I assume total responsibility for all costs associated with such medical treatment.
Emergency Contact Information:
PARENT/GUARDIAN OF PARTICIPANT:

First NameLast Name
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT NUMBERS:
PRIMARY
(999)999-9999
SECONDARY
(999)999-9999
EMAIL ADDRESS
example@example.com
NAME OF INSURANCE COMPANY:
POLICY NUMBER:
PLEASE LIST ANY HEALTH CONCERNS OR ALLERGIES:
PHYSICIAN’S NAME:

First NameLast Name
PHONE NUMBER
(999)999-9999
PLEASE LIST ANY MEDICATIONS PERSCRIBED TO YOUR CHILD THAT ARE CURRENTLY BEING TAKEN:
PHOTOGRAPHIC CONSENT, WAIVER AND RELEASE

For Consideration received, I/We hereby release and discharge the University from any and all claims and demands arising out of or in connection with the use of my photograph/my child's photograph, name, likeness or voice, including without limitation any and all claims for libel or invasion of privacy. This confirms that I am of full age and have the right to contract in my own name/my child's name. This acknowledges that I have read the foregoing and fully understand the contents thereof. This release shall be binding upon me, my heirs, legal representatives, and assigns.
Participant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Full Name

First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Full Name

First NameLast Name
ADDITIONAL INFORMATION (Provide any additional information you wish for the program staff to know about your son/daughter):
INFORMATION RELEASE

The information requested below will be used to assist us in providing services to your son/daughter. In order to provide the most effective services, we may need to obtain information from several sources, such as, middle schools, high schools, colleges, testing agencies, counselors, admission and financial aid officers, social workers, etc. ALL THE INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY RIGHTS AND PRIVACY ACT.

My signature below authorizes the TRiO Talent Search personnel to:

1. Request a copy of my high school and/or college progress reports, transcripts, test scores and/or documentation of behavior, grade promotion or graduation.

2. Request a copy of my middle school progress reports, report card, and/or documentation of behavior, grade promotion, retention, matriculation, and transfer records.

3. Request a copy of my financial aid applications and awards from the federal government, state funding agencies, and post-secondary institutions.

4. Request a copy of my test score reports (SAT, ACT, PSAT, PreACT, EOG, EOC, etc..) from all testing agencies or personnel.

5. Communicate with representatives from agencies or postsecondary institutions on my behalf.

AUTHORIZATION STATEMENT

I hereby authorize TRIO Talent Search personnel to contact and request information from, as well as supply information to, the above-mentioned parties.
Student Signature:

Clear
Student ID Number:
Parent/Guardian’s Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Parent’s Powerschool Username:
Password:

ELIZABETH CITY STATE UNIVERSITY