Tarleton State University-TS-Application Form

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Student Name: (First, MI, Last)

First NameLast Name

School:

Grade:

Student Email:

example@example.com

Student Phone #:

(999)999-9999

Mailing Address (apt # if applicable):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ethnicity (Please check all that apply):

Gender:

DOB:

mm-dd-yyyy

T-shirt Size:

Is your student a:

Mother/ Guardian Name:

First NameLast Name

Primary Phone:

(999)999-9999

Parent/Guardian Email:

example@example.com

Did the students mother/guardian earned a Bachelor’s Degree?

Are you a single parent?

Father/ Guardian Name:

First NameLast Name

Primary Phone:

(999)999-9999

Parent/Guardian Email:

example@example.com

Did the students mother/guardian earned a Bachelor’s Degree?

Are you a single parent?

Is English a Second Language for either parent/guardian?

Number of People in Household:

Family Income Status (check the box): Taxable Income (not Adjusted Gross Income) see 1040 tax form, line 15/1040EZ form, line 6.

Did Not File Taxes: What is the family’s income earned from work?

Family Income

Do you or your child receive any of the following? (Check all that apply):

I certify that the information provided is true and correct to the best of my knowledge. I understand this information is essential in assisting me/my child in
preparation for post-secondary education. I further understand all information received is for ETS use only and is held strictly confidential.

Parent Name:

First NameLast Name

Signature:

Date:

mm-dd-yyyy

If you are unsure if your family meets income guidelines, please call the Program Director Christi Barnes, at 254-459-5441 or Email: cbarnes@tarleton.edu

Do you have a desire to go to college?

Would you like a better understanding of the college process?

Would you benefit from educational resources from the TRiO ETS Program?

Would you like to be exposed to different career options?

What grades do you usually earn? (Check all that apply)

GPA:

Did any one refer the student to the TRiO ETS program?

If yes, who?

Please specify:

Are any family issues interfering with the student's education?

Progress towards secondary/postsecondary goals for the student?

Progress towards choosing a postsecondary field of study and career?

Any concern for student grades, assignments, attendance, and classroom behavior?

PERMISSION TO ACCESS SCHOOL RECORDS:

I authorize Educational Talent Search to access academic and personal information in the legitimate educational interest of my student including but not limited to: public assistance, free & reduced lunch documentation; standardized test scores (STAAR, SAT, ACT, THEA, GED); report cards; unofficial transcripts; official transcripts; attendance records; information about the status of postsecondary education admission/enrollment; financial aid documentation including FAFSA pin code, SAR, and award letters in accordance with The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99). I understand this information is essential in assisting me/my child in preparation for post-secondary education. I understand all information received is for ETS use only and is held strictly confidential.

I understand that I am giving the Tarleton State University Educational Talent Search Program’s Director and Advisor permission to access my students’ grade and attendance information directly from appropriate school personnel and to request other academic and behavioral information directly from school staff. I intend to give permission for Educational Talent Search to access and collect this information for the duration of my student’s participation in the program and throughout his or her high school and college career; however, if I choose to withdraw this permission, I can call the Program Director at 254-459-5441.

MEDIA RELEASE:

I hereby give ETS Program/Staff to permission to use my child’s picture/image and/or accomplishments as a result of my child’s participation in the program. These images/pictures may be used on program brochures, flyers, or be published on the program’s
website to activities and participation. I release any claims against Tarleton State University, the ETS Program and/or its staff for any damages, awards, claims or liabilities, which may arise from any unauthorized use or copyright violations of my child’s image, picture or work. If I choose to withdraw this permission, I can call the Program Director at 254-459-5441.

PARTICIPATION:

I understand this program is a voluntary program and that my child or I can elect to withdraw from the program at any time. I understand my child is expected to participate in the program and understand that a lack of participation is grounds for exit of the program.

By signing my name on the signature line, I certify that each response within this application is true and complete to the best of my knowledge. It also indicates that I acknowledge and give consent to the request of the Tarleton State University ETS program.

Parent Name:

First NameLast Name

Signature:

Date:

mm-dd-yyyy

Student Agreement Statement: I understand this program is a voluntary program and that my parents or I can elect to withdrawal from the program at any time. I understand I am expected to participate in the program and understand that a lack of participation is grounds for exit of the program

Student Name:

First NameLast Name

Student Signature:

Date:

mm-dd-yyyy

Educational Talent Search New Student Application

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

TO BE COMPLETED BY PARENT OR GUARDIAN

SECTION 6: STUDENT INITIAL ASSESSMENT

Parent Survey questions:

SECTION 7: PARENT/STUDENT CONSENT FOR SERVICES