Millersville University-TS-Application Form

MU Trio Application
What school are you attending?*

Columbia High SchoolDieruff High SchoolHarrisburg High SchoolJ.P. McCaskey High SchoolLebanon Senior High SchoolNorristown Area High SchoolPottstown Senior High SchoolReading Senior High SchoolWilliam Penn High School (York)
What is your current grade*

Grade 9Grade 10Grade 11Grade 12
What is your date of birth*

MonthDayYear
Date
What is your name?*

First NameMiddle InitialLast Name
Preferred Name*
What is your Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your e-mail address?*
example@example.com
What is your best daytime telephone number?*
(999)999-9999

Please select from the following that best describes your situation*

	Yes	No
A citizen or national of the United States
A permanent resident of the United States
In the United States for other than a temporary purpose and provides evidence from the Immigration and Naturalization service of his or her intent to become a permanent resident.
A permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands (Palau)
A resident of the Freely Associated States- The Federated States of Micronesia or the Republic of the Marshall Islands

Please select from the following that best describes your situation*

A citizen or national of the United StatesA permanent resident of the United StatesIn the United States for other than a temporary purpose and provides evidence from the Immigration and Naturalization service of his or her intent to become a permanent resident.A permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands (Palau)A resident of the Freely Associated States- The Federated States of Micronesia or the Republic of the Marshall Islands
Are you Spanish, Hispanic, or Latino, or none of these? (Mark all that apply)*

SpanishHispanicLatinxNone of these
Choose one or more races that you consider yourself to be*

WhiteBlack or African AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or Pacific IslanderOther
What is your gender?*
What is your gender?*

MaleFemale
What Primary language spoken at home?

EnglishSpanishFrenchOther
Are you currently in a dual enrollment program?

YesNo
Are you taking any rigorous enrollment courses? (select all that apply)

HonorsAP (Advanced Placement)IB (International Baccalaureate)
Do you participate in any of the following (check all that apply):

Upward BoundUpward Bound Math ScienceGear UpNone
Name of Parent or Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #*
(999)999-9999
Cell Phone #*
(999)999-9999
Highest Education Level*
Highest education level this parent has completed:*

Did NOT complete high school diploma/GEDHigh school diploma/GEDAssociate’s degreeBachelor’s degreeMaster’s degreePhD/MD/JD/Other advanced professional degree
Name of Parent or Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
(999)999-9999
Cell Phone #
(999)999-9999
Highest Education Level
Highest education level this parent has completed:*

Did NOT complete high school diploma/GEDHigh school diploma/GEDAssociate’s degreeBachelor’s degreeMaster’s degreePhD/MD/JD/Other advanced professional degree
Who do you live with?

Both ParentsMother OnlyFather OnlyNon-Parent Family MemberLegal GuardianFoster Family
Are you currently in foster care?

YesNo
If applicant is a foster child, please type "Foster Child" here*
Educational Talent Search is required by federal law and the U.S. Department of Education to document family size and income for every participant. All information remains confidential. Thank you in advance for your assistance.
Did you file a tax return for the most recent tax year*

YesNo
Did your parent(s) or guardian(s) file a tax return for the most recent tax year*

YesNo
Does your household receive assistance from any of the following programs?*

TANF (Also known as food stamps)Free or Reduced Lunchnone/no assistance programsOther
How many people (including yourself) live in your household?*
Please select the category that most accurately reflects your households taxable (not total or gross) income from last calendar year.*

$0-$22,590$22,591-$30,660$30,661-$38,730$38,731-$46,800$46,801-$54,870$54,871-$62,940$62,941-$71,010$71,011-$79,080$79,081 or above
Release of Information Student Applicant

Please read and sign the Release of Information statement. ETS collects data on all participants as required by the U.S. Department of Education. such data helps us assist students and serves as a measure of program performance. All data collected is kept under the strictest confidence and is protected by the Privacy act.

My signature below indicates that, to the best of my knowledge, the information on this application is complete and accurate. I hereby authorize Millersville Talent Search to obtain copies of academic and financial assistance records from educational institutions that I am attending now or from educational institutions I will attend in the future and consent to the use of photos for promotional and educational purposes.

Student Acknowledgement:

As a participant of the Talent Search Program, I understand that I must maintain a 2.0 GPA, work with my counselor to apply to postsecondary institutions, schedule college prep classes, and apply for financial aid. If I fail to do any of these requirements, I may be dropped from the program.
Signature*

Clear
Release of Information for Parent or Guardian

Please read and sign the Release of Information statement. ETS collects data on all participants as required by the U.S. Department of Education. Such data helps us assist students and serves as a measure of program performance. All data collected is kept under the strictest confidence and is protectedd by the Privacy Act.

My signature below indicates that, to the best of my knowledge, the information on this application is complete and accurate. I hereby authorize Millersville Talent Search to obtain copies of academic and financial assistance records from educational institutions that my student is attending now or from educational institutions that my student will attend in the future and consent to the use of photos for promotional and educational purposes.
Signature*

Clear

MU Trio Application