Mount Wachusett Community College-TS-Application Form

Educational Talent Search Application

Emergency Contact Information
This should be a non Parent emergency Contact
Name *

First Name Last Name
Relationship to student *
Home Phone *
(999)999-9999
Cell Phone *
(999)999-9999

Confidential Family Income and Information
We are required by the U.S. Department of Education to obtain family income and other eligibility information from all participants served by the ETS Program. Please complete the following and return this and all requested documents to the ETS Program office. All information will be held in strict confidence. Your application will not be reviewed without the following information.

You will need your tax return or information from your tax return to finish this page.
1. Did the family file a Federal Income Tax Return last year? *

Yes No
2. Please indicate your family’s taxable income. To determine your taxable income (which may be less than your gross income), refer to the taxable income line on the tax form that you used last year *
3. How many people (including both adults and dependants) were on your tax return last year *
4. Does your family receive any form of government benefits *

Yes No
If yes, please indicate which benefits

SNAP (Food Stamps) TANF (Welfare) SSI Housing Voucher (Section 8)
I verify that by signing this document and submitting the requested documentation that the information which I have provided is accurate to the best of my knowledge. I understand that this information will be held in complete confidence by the ETS Program at Mount Wachusett Community College.
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Signature

Clear
Date

Month Day Year
mm-dd-yyyy

Parent Consent and Liability Release
Parent/Guardian Name *

First Name Last Name
Applicant Name *

First Name Last Name
I, {parentguardianName77} give my son/daughter/ward, {applicantName} permission to participate in the Mount Wachusett Community College (MWCC) Educational Talent Search (ETS) Program. I also absolve MWCC, the ETS Program, their personnel and the Fitchburg, Gardner, and Leominster School Systems of any liabilities and claims arising from my child’s participation, and attendance in MWCC ETS program, including travel to and from such events and activities.

I consent to and authorize emergency and non-emergency medical care to be provided to my child in the unlikely event of a health problem, emergency or injury occurring during my child’s attendance in the ETS program. I give my consent and authorization to appropriate ETS members to use their judgment in seeking medical care for my son or daughter. I understand that an attempt will be made to contact me in the event that emergency medical care is needed.

I give permission for the ETS program to obtain the academic records/information for the above named student throughout his/her high school career and for six years following his/her graduation to allow for annual tracking of ETS participant’s education as is required by Federal Department of Education regulations to evaluate the ETS Program. I understand that this information will be held in compliance with FERPA and other applicable state laws and will only be accessible to appropriate program staff and Department of Education personnel.

I further give permission for the ETS program to use pictures, videotapes or audio recordings of the above named student for all program related purposes, including for publication in newspapers and other media. If I do not wish for the ETS program to use pictures, videotapes or audio recordings of the above named student I will submit written notification to the program and attach to this application. This consent will remain in effect until its written revocation is received by the ETS program at MWCC, 444 Green Street, Gardner, MA 01440.
Parent/Guardian Signature

Clear
Date

Month Day Year
mm-dd-yyyy

Student Code of Responsibility and Expectations
Applicant Name *

First Name Last Name
1. Students are expected to attend school every day.
2. Students are expected to meet with their TRIO advisor.
3. Students are expected to attend any and all workshops, and to fully participate in the program.
4. Students are expected to demonstrate model behavior in and out of school, including while on any and all field trips.
5. Students are expected to take advantage of everyopportunity offered in order to make their time with us as beneficial as possible.
6. Students are expected to share academic information with ETS staff in order to assist in planning and tracking. Student must also
give staff permission to access information relating to their academic progress.
7. Students are expected to have fun and do their best!

I have read the above rules and promise to uphold them and to be a good representative of my school and the ETS program. I understand that any serious breach of behavior may result in dismissal from the program.
Student Signature

Clear
Date

Month Day Year
mm-dd-yyyy

Student Needs Assessment
Name *

First Name Last Name
School *
Current Grade *
Address *

Street Address

Street Address Line 2

City State / Province
Zip Code *
Phone *
(999)999-9999
Check this box if you would not like to be added to the REMIND text list

Don't add me to REMIND text list
Email Address *
example@example.com
Check this box if you would not like to be added to the REMIND email list

Don't add me to REMIND email list

The following survey contains a number of statements regarding various aspects of student needs. We ask that each student give their honest opinion about how the ETS program can help to meet their particular needs. All answers will be kept confidential. Please circle that which best describes you.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

1. I need to get better grades in school.

2. I need to learn how to take better notes.

3. I need to learn test taking strategies and techniques.

4. I need to develop strong study skills and habits.

5. I need to learn how to read a text book more effectively.

6. I need to develop or improve my time management skills and habits.

7. I need to know how to prepare for a career that interests me.

8. I need to learn how to get involved in clubs and organizations.

9. I need help visiting college campuses.

10. I need to experience more cultural activities.

11. I need to learn which high school courses are necessary for college.

12. I need information on college prep courses and dual enrollment.

13. I need to learn about college programs and degrees.

14. I need to learn more about ACT / SAT testing.

15. I need help applying to college & understanding the process.

16. I need to learn more about filling out financial aid applications.

17. I need to learn about how to search for scholarships.

Student Signature

Clear
Date

Month Day Year
mm-dd-yyyy