Membership Application Form

ETS Membership Application

Educational Talent Search (ETS) is a free college-bound program designed to support students in grades 6 through 12 as they work toward high school graduation and pursue post-secondary education. ETS offers year-round programming, allowing participants to engage in activities until they enroll in a college program. As a federally funded TRIO program, ETS requires that at least two-thirds of its participants meet federal guidelines for being low-income and/or potential first-generation college students (meaning neither parent has earned a four-year college degree).
Student Full Legal Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Ethnicity:*

American Indian/Alaskan NativeAsianAfrican AmericanHispanicWhitePacific Islander/HawaiianMulti-Racial
US Citizen:*

I am a citizen or national of the United States.NoI am a permanent resident of the United States. Please list your permanent resident number.I am in the United States for other than a temporary purpose and provides evidence from the Immigration and Naturalization Service of his or her intent to become a permanent resident.I am a permanent resident of Guam, the Northern MarianaIslands, or the Trust Territory of the Pacific Islands.
Current Grade Level:*
School Attending:*
Student School E-mail *
example@example.com
Student Personal E-mail*
example@example.com
Student Phone Number*
Format: (000) 000-0000.
Parent Phone Number*
Format: (000) 000-0000.
Are you in any of the following programs:*

AVIDUpward BoundUB Math and ScienceVT Talent SearchNone
Applicant Agreement:If accepted to the program, I agree to attain all personal, academic, and career goals that I and the ETS staff set for myself. I will do my best to met program requirements by attending monthly meetings at my school and at least one field trip per year. I understand that I am expected to follow the same rules of conduct and dress code established by your school district. This is to include: 1) absolutely NO alcohol, drugs, or smoking at any time, 2) No profanity or horseplay at any time; and 3) fighting and disrespectful behavior towards others will not be tolerated. If I violate this policy, I shall be subject to disciplinary sanctions which may include suspension, and/or expulsion from the TRiO Educational Talent Search Program.I understand that while ETS services all types of students, the primary focus is to assist first-generation, low-income students, and if I do not fit that criteria I may be placed on a waiting list until a spot becomes available. If I am eligible, I agree to fill out the complete application in order to be accepted into the ETS program.*
Signature Date*

MonthDayYear
Date
Program Eligibility Documentation
Biological or Adoptive father. What is the highest level of education completed? Check all that apply:*

High School diploma or GEDAssociateBachelor/Master/DoctorateSome CollegeDid not complete high school
Biological or Adoptive mother. What is the highest level of education completed? Check all that apply:*

High School diploma or GEDAssociateBachelor/Master/DoctorateSome CollegeDid not complete high school
As a federally funded TRIO program, ETS requires that at least two-thirds of its participants meet federal guidelines for being low-income and/or potential first-generation college students (meaning neither parent has earned a four-year college degree).
Family Size

This only includes immediate dependents. In the case of divorce, please list the parent with whom the child resides the majority of the time.
How many people live in your household?*
exemptions claimed on line 6d of the federal tax return
Please list your brothers and/or sisters with their ages and current grade level.

AgeFirst NameLast NameGrade
Please list your brothers and/or sisters with their ages and current grade level.

AgeFirst NameLast NameGrade
Please list your brothers and/or sisters with their ages and current grade level.

AgeFirst NameLast NameGrade
Please list your brothers and/or sisters with their ages and current grade level.

AgeFirst NameLast NameGrade
Taxable Income Verification

Use your most recent tax return document to complete this section.
If you did not file a tax return or if you receive untaxed benefits, indicate the source of non-taxable income:*

Child Support ReceivedWelfare BenefitsTANFUntaxed Social Security BenefitsVeteran's BenefitsWorker's CompensationUnemployment BenefitsAny other untaxed income and benefits, such as Black LungNone
I hereby inform the Talent Search program that the taxable income (Most recent Form 1040, line 15) Yearly Income*
$ Taxable Income
I certify all information on this document is accurate.
Parent/Guardian Signature:*
Signature Date:*

MonthDayYear
Date
Release of Student Records
Student's Full Name for Release of Student Records:*
School Attending for Release of Student Records:*
Parent/Legal Guardian Name for Release of Student Records:*
Consent to Release Student Records
My student is participating in the Patrick Henry Community College's Educational Talent Search Program. I hereby authorize TRiO Educational Talent Search at Patrick Henry Community College to obtain and disclose the complete education records (Elementary, Middle, Secondary, and Post-secondary), as well as copies of school district and other partnering agency records for the student listed above, including but not limited to: Class schedules, Psychological and Educational Testing, Suspension and Disciplinary Records, ADA Information (504, IEP), FAFSA confirmation documents, and Grade Reports/Transcripts:*
Participant Contact & Medical Information

Parent/Guardian 1:*

Rows	Please list the following information:
Name
Relationship
Phone Number
Email

Parent/Guardian 2:*

Rows	Please list the following information:
Name
Relationship
Phone Number
Email

Emergency Contact 1:*

Rows	Please list the following information:
Name
Relationship
Phone Number

Please indicate medical conditions/allergies of student (disabilities, food allergies, etc.):*
If this does not apply to your student, type none.
List any medications student is currently taking (including over-the-counter):*
If this does not apply to your student, type none.
Does the student experience motion sickness?*

YesNo
Is the student a proficient swimmer?*

YesNo
Staff may perform basic first aid on my child (e.g. band-aids, cold pack)*

YesNo
Please call me for authorization if my child is requesting over-the-counter medications (e.g. pain relievers or motion sickness tablets)*

YesNo
My child has permission to participate in field trips, activities, and events sponsored by Talent Search and partner organizations (MHC After 3, AVID, etc.)*

YesNo
Activities/Promotional Release
I understand that the information provided is for use by P&HCC Talent Search and its partner agencies only and will remain confidential. I release the program from responsibility for any accidents, illnesses, or injuries that may occur during participation. I give permission for my child to participate in all Talent Search activities and for photos or videos to be used for documentation and promotion. In case of emergency, I authorize medical treatment for my child as deemed necessary. I will support my child’s involvement in ETS and confirm that all information provided is true and accurate.*
Date*

MonthDayYear
Date
Should be Empty:

ETS Membership Application

Program Eligibility Documentation

As a federally funded TRIO program, ETS requires that at least two-thirds of its participants meet federal guidelines for being low-income and/or potential first-generation college students (meaning neither parent has earned a four-year college degree).

Family Size

Taxable Income Verification

Release of Student Records

Consent to Release Student Records

Participant Contact & Medical Information

Activities/Promotional Release