Boys & Girls Clubs Of Central Georgia-TS 2-Application Form

*ALL TRIO PROGRAMS AND EVENTS ARE NO COST TO PARTICIPANTS*
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
School*

Appling Middle SchoolMiller Middle SchoolCentral High SchoolNortheast High School
Student Number
Grade*
Age*
Gender*

MaleFemaleOther
Ethnic Origin*

African American/BlackIndian/Alaska NativeAsian/Pacific IslanderEuropean American/WhiteHispanicMore than one ethnic origin
U.S. Citizen*

YesNo
If not a citizen, Visa Type/Number
Free/Reduced lunch participant?*

YesNo
TANF Recipient

YesNo
Grade Point Average (GPA)
Are you on social media?

FacebookInstagramTwitterOther
If so, how can we find you?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Email Address*
example@example.com
Student Cell Number*
(999)999-9999
Parent Cell Number*
(999)999-9999
Emergency Contact Person*

First NameLast Name
Relationship to you
Emergency Contact Number*
(999)999-9999
Student Signature*

Clear

PARENT/GUARDIAN INFORMATION
You Must Complete All Information Below to Have Your Application Processed
This information is strictly confidential and only for office use and funding purposes only
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Name

First NameLast Name
Email Address*
example@example.com
Student lives with: (check one)*

Both ParentsOne ParentParent/Step ParentFoster ParentLegal GuardianSpouse
Number of family members in home (Including you? (Brothers, Sisters, Parent(s), etc.) *
Select your family's Taxable Income from last year.

$0-12,525$12,526 – 16,875$16,876 - $21,225$21,226 - $25,575$25,576 - $29,925$29,926 - $34,275$34,276 - $38, 625$38,626 - $42,975$42,976+

Income Breakdown (If none, just enter 0)*

	Income Amount
Social Security Income
TANF
Child Support
Other Untaxed Income

Did either Parent GRADUATE from a four year college?*

YesNo
If yes, Name of College
I affirm that the information provided is complete and correct. Any deliberate falsification or omission of data supplied may result in denial of placement or dismissal from the Educational Talent Search Program.
Parent/Guardian Signature*

Clear

AUTHORIZATION
Student Name*

First NameLast Name
Authorization
for
Release of Student’s Records, Information and
Permission to Photograph/Video Student

Privacy Act
In accordance with the Family Educational Rights and Privacy Act, I understand that all information concerning my child and me is confidential and will not be revealed to anyone except Educational Talent Search Program Personnel.

I, Parent/Legal Guardian of , _{studentName}_ authorize the Superintendent of Schools or her/his Designee(s) to release all records listed below to the following Agency and its Designee(s):

Records:
Attendance Data
Psychological Education Reports Testing Data
Health Records
Grade Transcripts/Progress Reports Special Education Placement Data Student Clearinghouse
Social Security Numbers

Boys and Girls Clubs of Central Georgia

277 MLK Jr. Blvd
Macon, GA 31201
478-743-4153
www.bgccg.org

Student Schedules
I further authorize the release of all information regarding my child’s educational, physical and social adjustments in school, as long as s/he participates in the Educational Talent Search Program.

I also understand that prior to transfer, I may review and have all/any part of these records properly interpreted by making such request of the Principal or appropriate Board of Education Personnel.
Parent Name*

First NameLast Name
Permission to Photograph/Video Student: I agree to allow ETS and its constituents to photograph or digitally record my child for use in publication.*

YesNo
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

SCHOOL CONTRACT
Boys and Girls Clubs of Central Georgia

School Contract

As a student in the Boys and Girls Clubs of Central Georgia Educational Talent Search Project and as a major objective of ETS is to assist me with successful completion of secondary school and postsecondary planning/placement, I agree to:
1. Follow my Individual Graduation Plan
2. Give my ETS Program Staff all mid-term/nine weeks report cards and transcripts.
3. Discuss my changes in my academic plan with my parent (s) and ETS Program Staff.
4. Participate in career/educational activities, tours, and workshops.
5. Discuss my career aspirations and postsecondary plans with my parent(s).
6. Register and take the ACT/SAT as recommended by the Program Staff.
7. Research at least three (3) postsecondary institutions by completion of the eleventh (11th) grade.
8. As the parent(s) of an ETS student, I agree to participate in and support ETS and parents activities including chaperoning field trips, parent orientations, as well as Parent Advisory Board meetings
NOTE: If a student is to fully gain from the services offered by ETS, it is imperative that he/she attends counseling and academic sessions, school workshops, in addition to cultural /educational tours. All services offered by ETS are contingent upon one another. Failure to fulfill contract agreement could result in termination from ETS.
Student Initial Here to Acknowledge Reading of Contract*
Parent/Guardian Initial Here to Acknowledge Reading of Contract*

PARENT ASSOCIATION
Boys and Girls Clubs of Central Georgia

Educational Talent Search Parent Association

Parent/Guardian participation is critical to student success. As a member of our Parent Association, your assistance will help strengthen our program. If you are interested in serving please complete the following.
Parent Name

First NameLast Name
Email
example@example.com
Phone
(999)999-9999
Preferred method of contact (please select):

PhoneEmail
Are you interested in a leadership role in Association (please select):

YesNoMaybe