Educational Talent Search Information Sheet

What is the range of your total TAXABLE family income? “Taxable Income” is the
amount you earned after exemptions and deductions are figured (Line 6 of your 1040
EZ form, Line 43 of your 1040 form, or Line 27 of your 1040 A form). Provide your actual taxable income in the blank space and mark the appropriate box.

I hereby certify that all information in this application is true and correct. I also
understand that a false statement or misrepresentation will make the applicant ineligible for the Educational Talent Search Program (ETS).

I certify that this application has been filled out completely and correctly to the best of my knowledge. I understand that I am required to keep a grade point average of at least 2.3 to remain in the program and to attend special activities such as field trips. I further understand that I must attend at least TWO ETS activities each program year (between 9/1 to 8/31). I understand that if I attend a school other than an Akron Public School, I must give ETS a copy of each report card and must maintain contact with my appointed Educational Specialist.

I hereby grant permission for the officials at my child’s school to release copies of his/her permanent record, test scores, and grades to the Educational Talent Search Program at The University of Akron. Permission for the release of my child’s school records will remain in effect until he/she is no longer a program participant or until he/she has graduated from high school.

Confidentiality of school records is protected by state and federal law. Any person/facility receiving authorized information may not make further disclosure without the written consent of the person to whom it pertains.

I understand that I can revoke this authorization at any time by providing written notice to the person/facility who I designated to release the information. I understand that any information released prior to revocation cannot be retrieved and neither person/facility receiving the information will be held responsible for such.

I hereby release Educational Talent Search, The University of Akron, and its employees and agents from all legal responsibilities or liabilities that may arise from this act.

The University of Akron Educational Talent Search (ETS) is partnering with the Akron Public Schools and Summit Education Initiative to promote the success and academic achievement of students in Summit County. Summit Education Initiative (SEI) is
a nonprofit organization located in Akron, Ohio, dedicated to increasing educational attainment in Summit County, Ohio. In this work, SEI provides secure data access between Akron Public Schools and The University of Akron Educational Talent Search (ETS).

The Family Education Rights and Privacy Act (FERPA) protects students and parents by prohibiting most third parties from accessing student records, information, or data without clear permission from a parent or guardian if the student is under 18.

This form requests your consent to allow The University of Akron Educational Talent Search (ETS) to share the name, grade level, date of birth, student ID number and school of your child with SEI. Additionally, you are consenting to allow SEI to provide The University of Akron Educational Talent Search (ETS) access to your child’s Akron Public Schools data, including test scores, grades, attendance records, and results of student surveys. Your consent allows data to be shared in two directions: from The University of Akron Educational Talent Search (ETS) to Akron Public Schools; and from Akron Public Schools to The University of Akron Educational Talent Search (ETS). SEI is acting on behalf of both parties to match the information provided by The University of Akron Educational Talent Search (ETS) with your child’s school information, and to conduct research to determine the effectiveness of programs on student success and achievement.

Accessing or sharing records, information, or data will be done to promote and support your student’s academic success and achievement, and to evaluate services being offered. No records, information, or data will be used for any other purpose, and will not be shared with any party other than those listed in this release.

Parent/ Guardian Consent

I give consent for Summit Education Initiative to provide secure sharing of my child’s personally-identifiable information between The University of Akron Educational Talent Search (ETS) and Akron Public Schools. I understand the following information will be shared:
• Student Name, Grade Level, Date of Birth, and Student Id Number
• School District Name and School Building Name
• Course Grades and Grade Point Average
• National and State Test Results
• Attendance Records (Classroom and School Absence totals, both Excused and Unexcused)
• Results of Surveys Administered at the Building and/or at the District Level

I understand that my child’s information will only be shared between Summit Education Initiative, The University of Akron Educational Talent Search (ETS) and the Akron Public Schools, and that this consent may be terminated at any time by my written request as the parent/guardian listed below. It is also my understanding that this consent will last until my child is 18 years old: unless it is revoked by me in writing, my child is no longer affiliated with The University of Akron Educational Talent Search (ETS), or registered as a student in Akron Public Schools. As a legal guardian, I have the right to revoke consent at any time. I also have the right to obtain copies of any information about my child that is shared because of this
form.