Purdue University-Northwest-TS-Application Form

Purdue University Northwest - Hammond TRIO: Educational Talent Search Participant Application (Grades 6-8)

CLO Bldg., Room 176, 2200 169th Street, Hammond, IN 46323-2094 Phone: 219-989-2460 Fax: (219) 989-2094 Website: http://www.pnw.edu/ets/

Family Information
Father/Legal Guardian’s Name:*

First NameLast Name
Phone Number:*
(999)999-9999
Father has a 4-year college degree?*

YesNo
Mother/Legal Guardian’s Name:*

First NameLast Name
Phone Number:*
(999)999-9999
Mother has a 4-year college degree?*

YesNo
How many people live in your household including yourself?*

Please list everyone who lives in your household below (include yourself)*

	Name	Age	How are they related to you?	Name of School
1
2
3
4
5
6
7
8

Income Information
If your family filed a federal income tax return last year, please indicate your family’s annual taxable income (EZ Line 6; 1040 Line 43; 1040A line 27): Annual Taxable Income for the Previous Year (MUST BE WRITTEN ON THE LINE TO PROCESS APPLICATION. If taxable income was $0, write it on the line.) $*
Did your family participate or receive any of the following (Please check all that apply)*

Free/Reduced Lunch ProgramUnemployment BenefitsDisability BenefitsFood StampsSocial Security BenefitsPublic Aid (TANF)Child SupportNone of the above applyOther

Authorization and Release
The personal information that you give to the Educational Talent Search Program (ETS) is for the U.S. Dept. of Education. This information is protected by the Privacy Act. No one may see the information unless he/she work with or for the Educational Talent Search Program or are specifically authorized to see it. The information is necessary to determine if your child is eligible to participate in the Educational Talent Search Program and helps the U.S. Dept. of Education to measure his/her success. The U.S. Dept. of Education has the authority to gather such information (20 USC 1231a). Your child is not eligible for any services from the Educational Talent Search Program unless the information is given.
• I/we certify that all the information provided on this application is true and correct.
• I/we authorize my child’s school to release records (transcripts, standardized test scores, free and reduced lunch eligibility, class schedule, and attendance record) to the ETS Program at Purdue University Northwest- Hammond.
• I/we authorize ETS representatives to communicate with post-secondary institutions on my child’s behalf for up to six years post high school graduation. This authorizes the release of post-secondary records (admission, enrollment, and financial aid information) to the ETS program.
• I/we authorize the release and exchange of my child’s financial aid information from colleges and federal government to ETS.
• I/we understand that the completion of this application does not guarantee acceptance into the ETS program.
• I/we authorize the use of my child’s image in ETS publications and media releases to the ETS program.
Parent’s Signature*

Clear
Date*

MonthDayYear
Date
Student’s Signature:*

Clear
Date*

MonthDayYear
Date
ALL SECTIONS OF THIS APPLICATION MUST BE COMPLETED TO BE CONSIDERED FOR THE ETS PROGRAM

Purdue University Northwest - Hammond TRIO: Educational Talent Search Participant Application (Grades 6-8)