InstructionsThis form requires signatures from the student and parent/guardian before it can be

accepted. A digital signature is acceptable for this.

How to sign form electronically with Adobe Acrobat Reader

Adobe Acrobat Reader can be downloaded for free from https://acrobat.adobe.com

Use the Fill and Sign tool on right hand side.

Then you’ll see a pen “Sign” that you click on to create/insert a signature.

Create Signature either by drawing with your mouse/cursor or typing. Drag and drop the created signature onto the signature line.

If you need to sign with a different signature, click the minus sign next to the existing signature listed when you click the pen to clear it and make a new one. This will not affect any signatures that have already been placed.

Once you have completed and signed the form, please save this document and email it as an attachment to talent.search@kctcs.edu.

Educational Talent Search

Application 2020-2021

RETURN APPLICATION & DOCUMENTS TO:

Educational Talent Search Program, BCTC 164 Opportunity Way, N117

Lexington, KY 40511 Phone: 859-246-6574 email: talent.search@kctcs.edu

Educational Talent Search is a Federal TRiO Program funded by the U.S. Department of Education and sponsored by Bluegrass Community & Technical College, an equal opportunity institution.

If you need this form in a different format or need assistance with it, please contact the Talent Search at talent.search@kctcs.edu or call 859-246-6574.

164 Opportunity Way N117, Lexington, KY 40511

Phone 859.246.6574 Fax 859.246.4656

, KY

I understand that I can only participate in 1 TRiO Program at once (Educational Talent Search/Upward Bound).

Attach student’s MOST recent

grades/transcript!

Student is a U.S. Citizen: Yes No

RACIAL / ETHNIC BACKGROUND (Ethnic/Racial information is for statistical data only & will not be a factor in program eligibility): Check all that apply:

American Indian/Alaskan Native Asian/Asian American African American/Black Native Hawaiian/Pacific Islander

Hispanic/Latino Caucasian/White Other: (specify) ______________________________________________

Name of School Age Siblings in the Home Age Grade Current School Office Use

Parent/Guardian FIRST Name

Parent/Guardian LAST Name

Relationship to Student

Graduated from a 4-year college?

If YES, indicate name of college and year of graduation

YES NO

YES NO

►As parent/guardian of above student, I commit to attend at least one Family Night per year◄

Sign: _____________________________________________________ Date:___/___/_____

Part I—Student Information

Part II—Parent / Guardian Information

Male Female

Parent Email:______________________________________ Parent Cell Phone: _____________________________

The Parent/Guardian rights are with: Both Parents Single Parent Parent & Step-parent/partner

Court Appointed Foster parent (attach copy of foster-care documents)

Court Appointed legal Guardian (attach copy of guardianship documents)

Family Guardian, no court or legal document, but I have Educational/Medical Rights for said student.

►►►►►PARENT AGREEMENT◄◄◄◄◄

164 Opportunity Way N117, Lexington, KY 40511

Phone 859.246.6574 Fax 859.246.4656

2020-2021 APPLICATION PAGE TWO ~ EDUCATIONAL TALENT SEARCH

_____ YES, the family filed a Federal Income Tax Report for last year.

_____ NO, the family DID NOT file a Federal Income Tax Report for last year.

Indicate your TAXABLE INCOME amount from tax form:

__ 1040-A-line 27 __1040– line 3

$19,140 under

$25,860

32,580

$39,300

$46,020

$52,740

$59,460

$66,810

higher

Check all sources of income:

How many people live in household? ____ Does student participate in Free Lunch Program? YES NO

Social Services/K-Tap

Alimony

Unemployment

Veteran Benefits

SNAP Benefits

Child Support

Retirement

Disability

Social Security/SSI/

Survivor’s Benefits

Other (specify): _____

__________________________________

INFORMATION REQUESTS I would like more information about:

Part III—Student Needs Survey (Student MUST complete)

PLANS AFTER HIGH SCHOOL

College/University

Community College

Work

Military

Trade/Technical/Vocational School

Other: ________________________________

CAREERS What careers interest you?

_______________________________________

COLLEGE/UNIVERSITY What colleges or universities interest you?

________________________________________

I NEED TO:

get better gradesfind a tutor so I can be successful in my

classes learn how to take testslearn more about ACT/SAT testingdevelop stronger study habits & note takingskillslisten & ask questions more effectively in classlearn to better understand & further relationships with teachers & adultslearn how to get involved in clubs & organiza-tionsimprove my time management skillsget more information on high school graduation

requirements find more information on college prep coursesfind a college that is the best fit by visiting &

exploring different college campuses learn about college admission requirementslearn more about financing a college education

& scholarships explore & learn how to prepare for a career that

interests me gain awareness of different cultures by

experiencing more cultural activities know how to set, assess, and evaluate my goals

REFERRALS AND INFORMATION

Please let us know of any other issues you would like to discuss with us. _________________________________________

_________________________________________

_________________________________________

164 Opportunity Way N117, Lexington, KY 40511

Phone 859.246.6574 Fax 859.246.4656

X

X

Authorization to Obtain and Utilize ImagesBy signing below,

photograph videotape

Authorization to Release Academic/Educational Information

X

X

Parent/Guardian Printed Name Student Printed Name

Parent/Guardian Signature Date Student Signature Date

I agree to the above statements, and certify that, to the best of my knowledge, all information provided herein is correct.

Part IV—Authorizations & Signatures

**ALL STUDENTS PARTICIPATION AGREEMENT Active participation is expected of all students enrolled in the Educational Talent Search Program. Students must attend at least four services each year and maintain at least a 2.0 GPA to maintain enrollment in the pro-gram. Services are defined as: workshops, individual meetings, Family Nights, TRiO Day, college visits, and other trips & events provided by ETS. I agree to be an active participant in the Educational Talent Search Program by attending at least four services provided during the academic year. In order to participate in Spring Break trips/Summer camps, students must meet the following eligibility criteria: Attend workshops & other evening/weekend events regularly, earn & maintain a 2.5 GPA or higher, attend school regularly, and have not displayed any negative citizenship behaviors during the academic year. ____________________________________________ Signature Date

**HIGH SCHOOL STUDENTS ONLY First-time freshman under age 21 who enroll in a four-year degree program at a Kentucky public university must complete the Pre-College Curriculum. This includes: 4 English, 3 Math, 3 Science, 3 Social Studies, 2 Foreign Language (same), 1 Art Appreciation, 1/2 PE, 1/2 Health, 7 Electives (5 of which must be rigorous). I am on track in completing the Pre-College Curriculum. ____________________________________________ Signature Date

Part IV—Administrative Use ONLY

Date Received ___/___/_____ Exit Date: ___/___/_____

APPLICATION PAGE THREE ~ EDUCATIONAL TALENT SEARCH 2020-2021