EDUCATIONAL TALENT SEARCH @ LOS ANGELES SOUTHWEST COLLEGE
1600 W. IMPERIAL HWY., Los Angeles, CA 90047 ▪ (323)242-5523 ▪ Fax: (323) 242-5524
(Complete in Blue or Black Ink Only) Return complete applications to ETS staff or school counselor
PARTICIPANT & LIABILITY WAIVER
Student’s Name: ____________________________ Birth date:_____________________________
Parent/Guardian Name:_____________________________________________________________
PARENTAL CONSENT
As a parent and/or legal guardian of the student listed above, I/we authorize and permit my child to
participate in any and all academic year and summer component activities (classes, tutorials, advisement
sessions, workshops, field trips, work study internships, meetings, field trips, etc.) sponsored and/or
conducted by the Educational Talent Search Program at Los Angeles Southwest College. I/we also give
permission for my child to be transported between his/her school, the college campus, and the
scheduled events when the ETS program has scheduled events for its participants.
I/we do hereby grant permission to the Educational Talent Search Program at Los Angeles Southwest
College and its authorized representatives, to furnish first aid as my son/daughter may require, as well as
to seek medical attention through the nearest medical facilities when students are on field trips, on
campus, or other authorized activities. This permission is conditional upon the understanding that in the
event of serious illness or the need for hospitalization and/or major surgery, ETS will use all reasonable
efforts to contact me. Failure in such efforts should not prevent ETS from providing emergency
STUDENT SCHOOL RECORDS RELEASE AUTHORIZATION
I/we authorize Educational Talent Search Program at Los Angeles Southwest College to obtain
documents relative to and consistent with my child’s education. Such documents may include: a copy of
my child’s school transcript, test scores, ACT/SAT or CAHSEE/GED scores, and school lunch program
eligibility.
I/we authorize ETS to obtain documents related to my child’s application to or receipt of student
financial aid assistance (federal, state, or other), a copy of my award notification from college financial
aid office, and college admissions information. I/we understand the information above will be used to
monitor my child’s academic performance, assist in providing academic advisement, determine program
eligibility, and help with their college planning. I/we understand school records will only be used by ETS
and will not be shared with any other group.
The Family Educational Rights and Privacy Act (FERPA)e 20 U.S.C. 1232g, is the federal law providing for review and disclosure of
student educational records. The TRIO Programs at Los Angeles Southwest College will not permit access to or the release of personally
identifiable information contained in the student educational records to any party without the written consent of the student, except as
authorized by FERPA.
I certify by signing below I am agreeing to all the information below.
Parent/Guardian Signature:* ___________________________ Date: _______________
EDUCATIONAL TALENT SEARCH @ LOS ANGELES SOUTHWEST COLLEGE
1600 W. IMPERIAL HWY., Los Angeles, CA 90047 ▪ (323)242-5523 ▪ Fax: (323) 242-5524
Return complete applications to ETS staff or school counselor (Complete in Blue or Black Ink Only)
STUDENT INFORMATION
* REQUIRED INFORMATION
_______________________________
Last Name
________________________________
First Name
_______________________________
Middle Name
Street Address* ______________________________________ Apt#________ City* _______________________________ Zip Code*____________
Date of Birth*____________ * Email ___________________________________________Facebook:________________________________________
Home* (______)_____________________________
Gender* Male  Female
Cell (______)_______________________ Alt (_____)________________________
Do you have any learning disabilitues? Yes No Unknown
Ethnicity:*
 African- American (Black)
 Asian
 Caucasion
 Hispanic (Latino)
 Native American
 Pacific Islander
Other
Citizenship Status:*  US Citizen  Permanent Resident If yes, what is your Alien Registration #: _____________________  Other _______________________
EDUCATIONAL BACKGROUND
* REQUIRED INFORMATION
School Attending:*
Do you participate in any of the following programs? Check all that apply:
 Washington Preparatory
Animo-Locke 1
 Animo Locke 2
 Animo Locke 3
 Animo-Locke Tech
 Middle School 3
 Middle School 4
 Bret Harte
 Other _____________
 Educational Talent Search
 MESA
 Gompers
 Other_________________
*Do you wish to attend college/university after high school?
 Yes
Grade:__________
 AVID
 Upward Bound
 No  Uncertain
If yes, where ______________________
Grade Point Average: __________
PARENT OR GUARDIAN INFORMATION
* REQUIRED INFORMATION
___________________________________________
Print Father/Guardian’s name*
___________________________________________
Print Mother/Guardian’s Name*
___________________________________________
Relationship to Student*
___________________________________________
Relationship to student*
(_____)________________
Phone Number *
(______)____________________
Cell Phone
(______)_______________
Phone Number *
(_____)__________________
Work
___________________________
Email Address
(______)_________________
Work
(______)__________________
Cell Phone
__________________________
Email Address
DO YOU HAVE A U.S. FOUR-YEAR COLLEGE DEGREE?*:
DO YOU HAVE A U.S. FOUR-YEAR COLLEGE DEGREE?*:
 Y ES
 NO
 YE S
 NO
HOUSEHOLD INFORMATION
* REQUIRED INFORMATION
Does anyone in your household receive any of the following?
*SIZE OF FAMILY?: __________(# LIVING IN HOUSEHOLD)
(please check all that apply).
WHAT IS YOUR TAXABLE FAMILY INCOME FOR LAST CALENDAR YEAR?:
*Please check the appropriate
 $0-16,335
 $16,336-22,065
 $22,066-27,795
 $27,796-33,525
 $33,526-39,255
taxable income box:*
 $39,256-44,985
 $44,986-50,715
 $50,716-56,445
 $56,446+
 Unemployment
 Disability
Public Assistance
 Veteran’s Benefits
 Social Security
 Free/Reduced Lunch Program at School
 Ward/Dependent of court
 Otro: ______________
All information is kept confidential. This data is used to determine if your
child is eligible for this federally funded program.
I certify the information provided above is correct to the best of my knowledge.
Incomplete applications will not be accepted and returned to student.
Student Signature:*_____________________________________________
Parent/Guardian Signature:* _____________________________________
Date___________
Date___________
This program is 100% federally funded by U.S. Department of Education ($232,780 per year). Information provided above is necessary to determine if your child is eligible
to participate in program. Information is protected by Privacy Act.
For Office Use Only:
Date of entry: ________________ Class of: ___________ Letter Sent: _________________
Eligibility:  LI/FG  LI  FG OTHER
 Application Complete
Academic Advisor: _________________________
Program Coordinator: ______________________