STUDENT APPLICATION
*REQUIRED: 2.0 GPA and a Copy of Transcript**
*Please Use Black or Blue Ink ONLY. Do Not Use Pencil.
*Please make sure you check this application for any missing information.
Name: Last
Social Security # :_ _______________________
First
Mailing Address
or PO Box: ___________________________________________________________________________________
Address
Apt #
City
Zip Code
Home Phone:___________________________ Mom’s Cellular:________________________
Date
of Birth:___________________________ ❑ Male Month / Day / Year
Place
of Birth:____________________________ ❑ Female
Dad’s Cellular:__________________________
Student’s Cellular:______________________
Student’s E-Mail:
School & Grade Level
HIGH SCHOOL: ___________________________________ GRADE:
❑9
❑ 10
❑ 11
❑ 12
• What two careers are you interested in? 1)__________________________ 2)___________________________
Residency Status
❑
United States Citizen
❑
Permanent Legal Resident
❑
Other - specify i.e. INS application in progress
**Submit copy of verication**
Ethnicity
❑
❑
Native American
White (Caucasian)
❑
❑
**Submit copy Residency Card**
African American
❑
Asian
Hawaiian or Pacific Islander
• Language most often spoken at home:
For Office Use Only
ETS Verification
Date
ETS Verification
Date
❑ Hispanic / Latino
❑ Other ___________________________
❑ English ❑ Spanish ❑
Other_________________
Additional Information
Mark all that apply:
❑ Disabled ❑ Migrant Student ❑ Teenage Parent ❑ ESL
❑ Special Ed
❑ Foster Child
5240 N JACKSON M/S UC 59 FRESNO, CA 93740 559.278.2276
PARENT / FAMILY INFORMATION
This student lives with:
❑ Father
❑ Mother
❑ Stepfather
❑ Foster Parents
❑ Court Ordered Legal Guardian
❑ Stepmother
❑ OTHER _________________
_____# in Household
FATHER (Biological or Adoptive)
NAME:____________________________________________________________________________________
Last
First
Occupation/ Career :____________________________
Did he receive a university degree from a four year college in the USA ?
If so, what college?_________________________
Middle
❑ Yes ❑
No
MOTHER (Biological or Adoptive)
NAME:____________________________________________________________________________________
Last
First
Occupation/ Career :__________________________
Did she receive a university degree from a four year college in the USA?
If so, what college? __________________________
Middle
❑
Yes
❑
No
If this form is submitted after 01/31/2015 your family’s 2014 income information will be required
instead of the 2013 income.
For ______, which income tax form did you file? Attention Parent or Guardian
Form #
Line #
Taxable Income
❑
1040
Line 43
$____________
❑
1040EZ Line 6
$____________
❑
1040A
$____________
Line 27
The Educational Talent Search
Program office will not process any
applications without Parent Income.
Please make sure Parent Income
information is complete before you
submit. Please contact our office if
-OR-
Parents DID NOT file income tax forms this past year
❑
you have any questions. Hablamos
Español : 559-278-2276
-AND-
RECEIVED THE FOLLOWING (check all that apply):
Please indicate the Annual Benefited Amount below
❑ Social Security $_____________
❑ Disability $_____________
❑ Foster Child
$_____________
❑ Public Assistance (TANF, etc.) $_____________
❑ Unemployment Insurance $_____________
❑ Other (Please explain below) $_____________
___________________________________________
I/We, the undersigned, declare under penalty of perjury that all the income reported on this application is
true, complete and accurate to the best of my knowledge.
Parent /Legal Guardian’s Signature
Relationship to applicant
Date
The information is protected by the Privacy Act. No one may see the information unless they work with, or for the Educational
Talent Search Program, or are specifically authorized to see it. The information is necessary to determine if the applicant is eligible
to participate in the Educational Talent Search Program.
EMERGENCY INFORMATION
Please check all illnesses that apply to the applicant
❑ Asthma
❑ Convulsions
❑ Diabetes
❑ Epilepsy
❑ Fainting Spells
❑ Heart Trouble
❑ Kidney Trouble
❑ Nose Bleeds
❑ Rheumatic Fever
❑ Sinus Infection
❑
Allergic Reactions: __________________________________
❑
Prescribed Medication: ____________________
• Please explain if your son/daughter has suffered, or suffers from any other illness(es): __________________________
________________________________________________________________________________________________
• In case of emergency, who else can be notified? _____________________________________ __________________
Name
Phone #
• NAME of family physician or Clinic: _____________________________________ Phone #: __________________
MEDICAL CONSENT
I/we authorize staff members in the Central California Educational Talent Search Program at California State University, Fresno
to seek and authorize medical treatment for my son/daughter in the event of an emergency. "If an emergency arises requiring a major
surgical procedure, the program staff will attempt to reach me and be guided by my wishes; but if I cannot be reached, I authorize the
attending physician to proceed as deemed advisable."
ACTIVITIES CONSENT
It is herein requested that my son/daughter be permitted to participate in the following activity which may take place away from the
school premises. I have been advised of the contents of the State of California Education code section 35330 which states in part: "All
persons making the study trip or excursion shall be deemed to have waived all claims against the district of the State of California for
injury, accident, illness or death occurring or by reason of the study trip or excursion".
ACADEMIC RECORDS CONSENT
Pursuant to 20 USA 1231a of the Department of Education, the Educational Talent Search Program has the responsibility to request
from the applicant and the applicants parents and/or guardians any supporting documents to determine eligibility into the program. The
information is protected by the Privacy Act. No one may see the information unless they work with, or for, the Educational Talent Search
Program, or are specifically authorized to see it. The information is necessary to determine if the applicant is eligible to participate in the
Educational Talent Search Program and helps the program to measure the applicant’s success.
Parent Permission for Publishing Student Photo:
I grant permission for my child's image to be published on the Educational Talent Search website accessible to the World Wide Web
(Internet). The image will be used in relation to ETS activities and could take the form of a photograph or video. Only first name may be
used, and under no circumstances will any other personal information be published.
I/ we, hereby grant permission for my child to participate in the Educational Talent Search Program at California State University,
Fresno. Furthermore, I/ we give consent to my child’s school to make available to the Director of Educational Talent Search Program,
or to any member of the ETS Program staff the Director designates, any and all information pertaining to my child’s access to academic
records.
I/ we, the undersigned, declare under penalty of perjury that all the information reported on this application is true, complete and
accurate to the best of my knowledge.
______________________________________________
Student's Signature
_____________________________________________
Parent/ Legal Guardian’s Signature
____________________________________
DATE
_______
___________________
DATE
The contents of this application were developed under a grant from the Department of Education. However, these contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.
• FOR OFFICE USE ONLY •
Notes & Recommendations
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Approval Signatures
___________________________________________________
___________________________
College Counselor Signature
Date
___________________________________________________
___________________________
Director’s Signature
Date
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Rev 08/01/2015
First Generation & Low Income
Low Income / NOT First Generation
First Generation / NOT Low Income
Other