Albany State University-TS-Application Form

Albany State University Educational Talent Search

Address: 2400 Gillionville Rd. | Albany, GA 31707

Phone: 229.500.4803

CONFIDENTIALITY STATEMENT:

This information will be kept in strict confidence and will not be revealed to anyone except Albany State University Educational Talent Search (ASU ETS) personnel per the Family Educational Rights and Privacy Act (FERPA).

1. Parent/Guardian's Name

First NameLast Name

2. Parent's Email Address

example@example.com

3. Parent's Cell Phone Number

(999)999-9999

4. Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

5. Student's Name

First NameLast Name

6. Student's Personal Email Address (Not Docostudents)

example@example.com

7. Student's Cell Phone Number

(999)999-9999

8. Student's Date of Birth

mm-dd-yyyy

9. Student's Age

10. Gender

Other

11. School

12. Grade

13. Grade Point Average

14. Guidance Counselor's Name

First NameLast Name

14. Please select any other programs the student participates in:

15. Is the student a U.S. Citizen or Permanent Resident?

16. Ethnicity

17. Does the student have any documented disabilities?

18. If you answered yes to the previous question, please explain:

If you answered no, insert N/A

19. Emergency Contact

First NameLast Name

20. Relationship to Student

21. Emergency Contact Phone Number

(999)999-9999

22. I hereby give ASU ETS permission to use my child’s image/picture and/or accomplishments as a result of my child’s participation in the program. These images/pictures may be used on program brochures, flyers, newsletters, social media posts, or be published on the program’s website for activities and participation.

23. Dear Parent/Guardian: The Department of Education in Washington D.C. funds Albany State Educational Talent Search. We are required to provide services to a portion of students who meet financial and educational criteria. Please help us meet these criteria by completing the following questions:

24. Student lives with:

25. Including you, what is the number of people living in your household:

26. Your household income last year: (Refer to Line 11b on your 2022 tax return)

27. Indicate the yearly amount your household receives from Aid to Families with Dependent Children (AFDC):

If you do not receive AFDC, insert N/A

28. Indicate the yearly amount your household receives from Child Support:

If you do not receive Child Support, insert N/A

29. Indicate the yearly amount your household receives from Social Security Benefits:

If you do not receive Social Security Benefits, insert N/A

30. Indicate the yearly amount your household receives from Disability:

If you do not receive Disability, insert N/A

31. Indicate the yearly amount your household receives from Unemployment:

If you do not receive Unemployment, insert N/A

32. I understand that the financial information I provided is correct, to the best of my knowledge, and will be used to help determine if financial criteria are met.

33. PRIVACY ACT: Your information will be kept in strict confidence only to be shared with ASU ETS personnel per FERPA. (i. Duty to Report: ASU ETS is mandated by the state of Georgia to report all non-accidental injuries, abuse, child abuse, neglect, and sexual offenses to law enforcement.)

34. Is the student at a Title I School and receives free or reduced lunch?

35. Did you or your spouse receive a Bachelor's Degree?

36. What is the highest educational level you have completed?

37. What is the highest educational level completed by your spouse?

36. With my signature below (parent/guardian, or student if 18 or over), I hereby grant permission to the staff of Albany State University Educational Talent Search to access and/or receive copies of my (my child's) school records, academic transcripts, grades, progress reports, report cards, EOC scores, other test scores, promotion/retention status, financial aid acceptance, post-secondary enrollment status, and any other academic information and test results. These records will be used to assess student needs, monitor student progress, document eligibility for the program, and reporting purposes.

I certify the information given in this application is complete and accurate. I understand that to make false or fraudulent statements within this application may result in termination from the program.

Parent's Signature:

Date:

mm-dd-yyyy

39. I authorize the Educational Talent Search Program of Albany State University to access and/or receive copies of my academic transcripts, grades, report cards, EOC scores, other test scores, promotion/retention status, financial aid acceptance, post-secondary enrollment status and any other academic information and test results as necessary determine eligibility for services.

I certify the information given in this application is complete and accurate. I understand that to make false or fraudulent statements within this application may result in termination from the program.

Student's Signature:

Date:

mm-dd-yyyy

ASU ETS Application