Application for Talent Search Southern Arkansas University 100 E University MSC 9277 Magnolia, AR 71753-9277 Name* First Last Date of Birth* MM slash DD slash YYYY Social Security Number*Please enter a number from 000000000 to 999999999.Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Emergency Contact* First Last School* Grade Level*6789101112Age*Please enter a number from 10 to 20.Gender*MaleFemaleAre you a United States citizen?* Yes No Alien Registration Number*Nationality (check all that apply)* White/Caucasian Hispanic/Latino Native Hawaiian/Pacific Islander Black/African American Asian Other (please specify) * Household (check all that apply)* Single Parent Guardians Step Parent Both Parents Grandparents Other (please specify) * Which best describes your grades?*AA-BBB-CCC-DDD-FAre you enrolled in a TRiO program?* Yes No Listed below are some possible Educational Talent Search activities. Check the area(s) with which you would like information or need help with:* College Awareness (Admission, Financial Aid, Campus Tours, Scholarship Information, ACT Information) Career Awareness (Career Planning, Goal Setting, Interest Inventory, Guest Speakers, Decision Making) Academics (Study Skills, Test-Taking Skills, Time Management, Course Selection) Character Development (Peer Pressure, Self-Esteem, Bullying, Cultural Experience, Listening Skills) Tutoring (Math, English, Science, Social Studies) Other (please list) *Which do you plan to enroll in after completing high school?* College/University (4 year) Community College (2 year) Career Training Program Military Program Undecided In order to participate in Educational Talent Search I agree to: maintain a 2.0 or better GPA to remain in the program; attend and participate in all scheduled meetings, workshops, tutoring, or mentoring sessions; have a desire to go to college; refrain from having discipline/behavioral problems; have respect for self and others; successfully be promoted to next grade; attend school regularly; seek help with academic or personal problems; and enroll in post-secondary program after graduation. By checking this box I, as student, am providing an electronic signature that I have read the above statement and agree to its terms. For my child to remain eligible to participate in Educational Talent Search, I will: immediately notify an Educational Talent Search Counselor if my child receives disciplinary action at school; be involved with Educational Talent Search activities as much as possible; attend at least one parental workshop provided by Educational Talent Search; and notify the Educational Talent Search office about any changes in contact information. By checking this box I, as parent, am providing an electronic signature that I have read the above statement and agree to its terms. Mother's Name* First Last * Parent (biological or adoptive) Guardian Father's Name* First Last * Parent (biological or adoptive) Guardian Mother's Employer* Father's Employer* Mother's Phone Number* Father's Phone Number* Mother's Highest Education Level Completed* High School/GED or lower Associate Degree (2 year) Bachelors Degree (4 year) or higher Father's Highest Education Level Completed* High School/GED or lower Associate Degree (2 year) Bachelors Degree (4 year) or higher Check the following services which your family receives: Free School Lunch Reduced Lunch Please indicate your Taxable Family Income from last year after deductions. This in not your Adjusted Gross Income. (found on Form 1040 - line 43; Form 1040A - line 27; and Form 1040EZ - line 6)* $0 - $19,140 $19,141 - $25,860 $25,861 - $32,580 $32,581 - $39,300 $39,301 - $46,020 $46,021 - $52,740 $52,741 - $59,460 $59,461 - $66,180 Over $66,181 I/We declare that no federal tax income was filed for the last tax period because my gross income was insufficient to require filing. Please check your form of income:* Disability Retirement Unemployment Child Support Social Security Veterans Benefits Welfare/Social Services Aid to Families with Dependent Children (AFDC) Other Total number of family members living at home (including applicant):* 1 2 3 4 5 6 7 8 or more I am aware that my child has shown interest in the program. I hereby authorize TRiO Educational Talent Search Program to contact and request information from, as well as share information with my child's school, teachers, and counselors. I hereby grant permission for he release of my child's high school records, transcripts, and all other achievement records to the Southern Arkansas University Educational Talent Search Program. I gran permission to the Educational Talent Search Program to treat (over the counter medication) to my son/daughter for any minor illness that they may encounter while at an Educational Talent Search sponsored event. I give permission to the Southern Arkansas University Educational Talent Search Program to arrange transportation for my son/daughter, to and from Educational Talent Search sponsored events, in vans, buses, or other vehicles driven or arranged by the Southern Arkansas University Educational Talent Search Program and seek medical assistance in the case of an accident. I give my son/daughter permission to be interview and/or photographed by digital, still photo film, or video recorder by Education Talent Search Program to use on radio, TV, printed media, social sites, or in project documentation and promotional materials. Our signatures below indicate our commitment to the TRiO Educational Talent Search Program. I consent to my child using the Internet and other technology and accept responsibility for appropriate use thereof. I understand that Education Talent Search is a federal program authorized by the U.S. Department of Education. I also understand that the information I have provided will be used to document my eligibility for the Educational Talent Search Program. I understand that the information provided on this application will be held confidential by the ETS staff.* By checking this box I, as parent, am providing an electronic signature that I have read the above statement and agree to its terms and certify that all the information I have provided on this form is true and accurate.