ETS Membership Application
Educational Talent Search is a free college bound program designed to assist students in grades 6th through 12th to graduate from high school and pursue post-secondary education. ETS offers full-year programming. In which participants may attend activities until they become enrolled in a college program.
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
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Colorado
Connecticut
Delaware
District of Columbia
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Hawaii
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Social Security Number:
*
Required for enrollment
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Ethnicity:
*
American Indian/Alaskan Native
Asian
African American
Hispanic
White
Pacific Islander/Hawaiian
Multi-Racial
US Citizen:
*
Yes
No
Other
Current Grade Level:
*
Please Select
rising 6th
6th
7th
8th
9th
10th
11th
12th
School Attending:
*
Please Select
Fieldale-Collinsville Middle School
Laurel Park Middle School
Martinsville Middle School
Bassett High School
Magna Vista High School
Martinsville High School
Patrick County High School
Blue Ridge Elementary
Hardin Reynolds Memorial
Meadows of Dan Elementary
Stuart Elementary
Woolwine Elementary
Benjamin Franklin Middle School
Franklin County High School
Parent E-mail
example@example.com
Student School E-mail
*
example@example.com
Student Personal E-mail
*
example@example.com
Student Phone Number
Parent Phone Number
*
Are you in any of the following programs:
*
AVID
Upward Bound
UB Math and Science
VT Talent Search
None
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.
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Signature Date
*
-
Month
-
Day
Year
Date
Program Eligibility Documentation
Parent Education
Please indicate whether your biological or adoptive mother has a Bachelor degree or higher:
*
Yes
No
Please indicate whether your biological or adoptive father has a Bachelor degree or higher:
*
Yes
No
Do you receive free or reduced lunch?
*
Yes
No
Did not apply
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.
Age
First Name
Last Name
Grade
Please list your brothers and/or sisters with their ages and current grade level.
Age
First Name
Last Name
Grade
Please list your brothers and/or sisters with their ages and current grade level.
Age
First Name
Last Name
Grade
Please list your brothers and/or sisters with their ages and current grade level.
Age
First Name
Last Name
Grade
Taxable Income
Use your most recent tax return document to complete this section.
Check the income range that is reflected on your TAXABLE INCOME on your Federal Tax return.
*
$0-$21,870
$21,871-$29,580
$29,581-$37,290
$37,291-$45,000
$45,001-$52,710
$52,711-$60,420
$60,421-$68,130
$75,000 and above
If you did not file a tax return or if you receive untaxed benefits, indicate the source of non-taxable income:
*
Child Support Received
Welfare Benefits
TANF
Untaxed Social Security Benefits
Veteran's Benefits
Worker's Compensation
Unemployment Benefits
Any other untaxed income and benefits, such as Black Lung
None
I certify all information on this document is accurate.
Parent/Guardian Signature:
*
Signature Date:
*
-
Month
-
Day
Year
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:
*
Activities/Promotional Release
As the legal parent or guardian of the ETS participant, I give permission for my child to participate in educational program-sponsored activities. I also give permission for the use of my child's name and/or photograph for editorial, recruitment and/or educational purposes. I will do my best to encourage and participate in my child's ETS activities. I certify that the information on this form and any attachment is true, complete, and accurate to the best of my knowledge.
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Date
*
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Month
-
Day
Year
Date
Student's Signature
*
Date
*
-
Month
-
Day
Year
Date
Participant Contact & Medical Information
Parent/Guardian 1:
*
Please list the following information:
Name
Relationship
Phone Number
Email
Parent/Guardian 2:
*
Please list the following information:
Name
Relationship
Phone Number
Email
Emergency Contact 1:
*
Please list the following information:
Name
Relationship
Phone Number
Emergency Contact 2:
*
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?
*
Yes
No
Is the student a proficient swimmer?
*
Yes
No
Staff may perform basic first aid on my child (e.g. band-aids, cold pack)
*
Yes
No
Please call me for authorization if my child is requesting over-the-counter medications (e.g. pain relievers or motion sickness tablets)
*
Yes
No
My child has permission to participate in field trips, activities, and events sponsored by Talent Search and partner organizations (MHC After 3, AVID, etc.)
*
Yes
No
I understand that the information I have provided here is for the use of P&HCC Talent Search and partner agencies only and will remain confidential. I relieve the program of any responsibility for any accidents, illnesses, or injuries, which may result from participation and allow them to take pictures for program documentation and promotion.Be it known that I, as parent/guardian of the named student, hereby grant unto any medical doctor or hospital my consent and authorization to provide such aid, treatment, or care to said student as, in judgement of the doctor or hospital, may be required on an emergency basis in the event said student should be injured or stricken ill while participating in a Talent Search sponsored event or field trip.
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Date
*
-
Month
-
Day
Year
Date
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