Educational Talent Search Application - Prairie State College

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Prairie State CollegeEducational Talent SearchInformation Waiver Form (ETS)I hereby give permission for ________________________________________ to participate in the Educational TalentSearch Program which will provide tutoring, mentoring, field trips, and support services.In addition to assisting our staff in providing counseling the student, the information that you provide will be used forpreparing statistical reports. These reports will protect your anonymity, and will be confidential, as they will be of asummary nature only.In order to provide effective services for our students, we may need to obtain additional information from several sourcesto verify a student’s eligibility within the program such as: High Schools, Colleges, and Testing Companies.Your signature below authorizes ETS to:• Request a copy of Elementary, High School/ or College transcripts• Request a copy of your financial assistance applications from the Federal Government, StateFunding Agencies, a Post-secondary Educational Institution, and / or American College TestingCompany or College Entrance Examination Board• Request a copy of attendance records• Request a copy of public aid information• Request a copy test score reports such as IGAP, IOWA, ACT, PSAT, SAT, TAP, and the CaseTest• To supply college representatives with student information for the purpose of providing collegeopportunities• Take pictures of participants during activities to be used in promotional publications____________________________Student Signature___________Date____________________________ ____________________________ __________Signed Parent / or Guardian Print Name DateWVR 8-14
TRiO Participant ApplicationPlease Type or Print in Blue or Black Ink.PROGRAM: Educational Talent SearchSTEP 1 - STUDENT INFORMATIONLast Name: First Name: Middle Initial:Street Address:Apartment#:City: State: Zip: E-Mail:Phone Numbers:(H) _________________________________________(W) ________________________________________(C) _________________________________________School/College currently attending:_____________________________________________________________________School Student ID# (if applicable): ______________________________________Social Security Number:-- --Grade Level: _____________G.P.A.: ______________STEP 2 – STUDENT INFORMATIONEthnicity: American Indian or Alaska Native White Asian Native Hawaiian/Pacific Islander Black or African American More than one race Hispanic or LatinoGender: Male FemaleBirth Date: _____/_____/_____Age:_________________STEP 3 – STUDENT INFORMATIONAre you a U.S. Citizen? Yes NoIf you are not a U.S. Citizen, are you Yes Noa Permanent Resident?Enter Permanent Resident Alien Number:ASTEP 4 – PARENT INFORMATIONHas your father received/earned a four- Yes Noyear degree? If yes, name of school _____________________________Has your mother received/earned a four- Yes Noyear degree? If yes, name of school _____________________________Which parent did you regularly reside with and receive support from Mother Both Mother and Fatherduring your childhood (i.e., until you were 18 years old)? Father Neither Mother nor FatherSTEP 5 – STUDENT INFORMATIONIf you are at least 24 years old, ignore the questions in STEP 5 and skip ahead to STEP 6.If you are less than 24 years old, answer the questions in STEP 5 and then go to STEP 6.Are you in college and working on a master’s or doctorate program (e.g., M.A., MBA, MD, JD, PhD, EdD? Yes NoAre you married? Yes NoDo you have children who receive more than half of their support from you? Yes NoDo you have dependents (other than your children or spouse ) who live with you Yes Noand who receive more than half of their support from you?Are both of your parents deceased, or are you (or were you until age 18) a ward/dependent of the court? Yes NoAre you a veteran of the U.S. Armed Forces? Yes NoSTEP 6 – PARENT INFORMATIONYou must answer the questions in STEP 6 if you are at least 24 years old or you answered YES to any of the questions in STEP 5.Your parent(s)must answer the questions in STEP 6 if you are less than 24 years old and you answered NO to all of the questions in STEP 5. Note: If you are acollege student and dependent on your parents (i.e., you are less than 24 years old and you answered NO to all of the questions in STEP 5), speakwith your FCEA advisor.TS1 8-14
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Educational Talent Search Application - Prairie State College

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