Educational Talent Search Program Application Florida International University

Last Name First Name M.I.

Street Address Apartment/Unit #

City State ZIP

Student Contact # _________________________________________ Email _________________________________________________

School _______________________________________________ Student ID# _________________________ Grade ________ GPA ________

Social Security #:____________-__________-_________________ Will be kept confidential

Sex: Male Female Birthdate _____ /_____ /_____

Ethnic Background American Indian Asian Black/African American Hispanic/Latino White Pacific Islander

Other (Please Specify) ____________________________________________

Are you a citizen of the United States? YES NO If not, provide your Resident Alien #: ____________________________

Mother/Guardian Name: ________________________________________ Father/Guardian Name: ____________________________________

E-mail 1: _____________________________________________________ E-mail 2: ________________________________________________

Cell Phone #: Cell Phone #:

Student lives with: Mother Father Both

ELIGIBILITY CRITERIA - All information must be complete to be eligible for ETS services.

Funding is provided by the US Department of Education and requires specific documentation for enrollment into the TRIO Educational Talent Search Program. The information is protected by the Family Rights and Privacy Act. The information is used to determine if the student is eligible to participate in the ETS program. This section must be completed by the parent/guardian.

First Generation Status (Parents’ or Guardians’ educational level)

Please check the highest level of education completed by the student’s mother/female guardian:

Some High School Associate’s Degree Bachelor’s Degree

If Bachelor’s Degree, Name of Institution Attended: __________________________________________________________________

Please check the highest level of education completed by the student’s father/male guardian:

If Bachelor’s Degree, Name of Institution Attended: __________________________________________________________________

Income Status

If your family is using any of the following programs, please check:

TANF WIC Food Stamps Social Security Unemployment SSI Child Support Federal School Lunch Program

Is this student a Ward of the Court? Yes No

Taxable Income – Net Adjusted Gross Income (check one- see 1040 tax form, line 43 or 1040A tax form, line 27, or 1040EZ, line 6)

Family members living in household ________

$0-$18,735$18,736-$25,365 $25,366-$31,995

$31,996-$38,625$38,626-$45,255$45,256-$51,885

$51,886-$58,515$58,516-$65,145$65,145 or above

Federal TRIO Programs Current Year Low-Income Levels Effective 1/19

Guardian

High School

Bachelor’s Degree

Graduate School

Some High School High School Associate’s Degree Graduate School

STUDENT INFORMATION

I was referred to ETS by: My child's school Community Organization Personal Referral by _________________________________

STUDENT ASSESSMENT – THIS SECTION TO BE COMPLETED BY STUDENT ONLY

What are your plans after you graduate from high school?

2-Year College 4-Year College Technical/Vocational School Work Military Other: _____________________

What services and information would you like to receive from FIU Educational Talent Search? (check all that apply):

Tutoring If so, in what subjects? _____________________________________________________

Academic Counseling Mentoring Information on high school selection Career Information

Help preparing for college entrance exams (SAT/ACT Prep) Financial Education Exposure to college campuses

Information on the college admissions process and help completing college applications.

Information on college costs and help completing financial aid applications

Information on how to strengthen my study and test taking skills Assistance with the college enrollment process

Information about the benefits of going to college and earning a degree

Currently, your top three choices for high school are: Top three choices for college:

_________________________________________________________________________________________________________

Currently, your top three choices for your future career are:

______________________________________________________________________________________________________________________ What do you see as your strengths (academically or socially)?

______________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

What would you like to improve (academically or socially)?

___________________________________________________________________________________________________________________If accepted, I agree to always treat myself, other students, and program staff with respect.

I also agree to work hard in school, participate in ETS sessions, events, and workshops throughout middle and high school, in order to prepare myself for success in school and in college.

Student Signature: _____________________________________________ Date: _________________________

PARENT AGREEMENT - THIS SECTION TO BE COMPLETED BY PARENT ONLY

I certify that the information given here is true and correct.

I give my consent for my child to attend field trips, cultural events and workshops.

I relieve Educational Talent Search at Florida International University of any responsibility for accidents, illnesses, or injuries including death that may result from participation. I release the released parties from all claims, damages, actions, or causes of actions, which may occur due to any decisions made with respect to the medical care or treatment of my child.

I authorize the use of my child’s name, photograph, and statements, for use in ETS publications, newsletters, and websites.

I authorize counselors or schools to release my child’s transcript information regarding educational progress, attendance, testing, and enrollment status to ETS at FIU.

This consent will remain in effect for as long as my child is a participant in ETS.

Parent/Guardian Signature: _______________________________________ Date: ________________________

For Office Use Only:

Director Signature:_____________________________________________ Enrollment Date: __________________________