Educational Talent Search Pasadena City College Pasadena, CA 91106 (626) 585-7011 Fax: (626) 585-7969

Section 1 Student Information Legal Name: ___________________________________________ Social Security # _______-_____________

(Last) (First) (MI)

(For Reporting

Purposes Only)

Mailing Address: __________________________________________________________________________

(City) (Zip Code) (State)

Home Phone: (____)_________________________ Student Cell Phone: (____)________________________ Sex: Male Female Birthdate: ____/____/____ _______________________________ Birthplace:

Email Address: _____________________________________ Expected Graduation Year: ________________ Ethnic Background: American Indian Hispanic/Latino Asian Black/African American

White Pacific Islander Other (please specify) _________________________________ School: _____________________________________________ Grade: _____________ GPA: _____________ Are you currently enrolled in any of the programs listed below: AVID Puente Upward Bound (if yes, which one? ___________________________________) Other ______________________________________________ programs Not enrolled in any of these

Names of siblings currently in Educational Talent Search: __________________________________________ How did you hear about Educational Talent Search? ______________________________________________ Section 2 Eligibility Criteria All information must be complete to be eligible
Funding is provided by the US Department of Education and requires specific documentation for enrollment into the TRIO Educational Talent Search Program. The information is protected by the Family Rights and Privacy Act. The information is used to determine if student is eligible to participate in ETS program. A. Citizenship Status: Are you a Rev. 03/12 Student ID #_________________________________

 US Citizen or Permanent Resident: A____________________

Alien Registration #

B. First Generation Status (Parents or Guardians educational level)

Mother has a 4-year college degree (BA/BS) Yes No Highest Grade Completed __________ Father has a 4-year college degree (BA/BS) Yes No Highest Grade Completed __________
C. Income Status: Taxable parent/guardian income for 2010.

a. I/we claimed ___________exemptions. (See line 6 d of your 1040 or 1040A tax form) b. Taxable income (check one - see 1040 tax form, line 43 or 1040A tax form, line 27) $0-$16,755 $28,636-$34,575 $46,456$52,395 $16,756-$22,695 $34,576-$40,515 $52,396$58,335 $22,696-$28,635 $40,516-$46,455 $58,335 or above Parent/Guardian Signature:____________________________________ Date: __________________ Section 3 Family Information Mother/Guardian name: _____________________ Occupation:______________________________ __ Place of Employment: _______________________ Work or Cell Phone: (____)____________________ (please circle)
Does Mother/Guardian live in the home? Yes No

Father/Guardian name: ______________________ Occupation:______________________________ __ Place of Employment: _______________________ Work or Cell Phone: (____)____________________ (please circle)
Does Father/Guardian live in the home? Yes No

Does the student live in a foster home or is he/she a ward of the court? Yes No List all persons currently living in your home (including yourself): Name Age Relationship to student

Section 4 Parent/Guardian Authorization By signing below, I/we authorize and

1) All of the information I have provided on this application is accurate and correct. 2) Educational Talent Search (ETS) is granted access to my students school transcripts, standardized test scores, SAT/ACT scores, and any other information which is necessary for participation of the student in the ETS program. 3) ETS may use my students picture in program publication materials (brochures, web sites & displays). 4) Should my student require medical attention while participating in ETS activities and I cannot be contacted, I give my consent to medical examination and treatment deemed necessary by the attending medical professional. 5) ETS is granted access to students college enrollment, retention, and completion information. 6) ETS is granted access to students financial aid information from colleges and the federal government. 7) We, the parents/guardian of above stated student agrees to encourage our son/daughter to attend college immediately following high school graduation. Parent Signature (Please sign in ink): _______________________________________Date:____________ Section 5 Student Contract In order to participate in the Educational Talent Search Program, I agree to: Be committed to my education and the Apply for financial aid during the spring ETS program of my senior year Attend ETS workshops, field trips, and Graduate from high school activities Enroll in the college of my choice the Communicate with my ETS advisor about semester after I graduate from high my educational and personal goals school Enroll in courses that are required for Keep in touch with the ETS program while admission to college I am in college to keep them informed on Achieve and maintain at least a 2.0 GPA how I am doing Apply for college during my senior year Student Signature (Please sign in ink): __________________________________________________________ Student Name (Printed): _________________________________________ Date: _______________________ Section 6 Student Needs Assessment Im interested in. (circle as many as youd like) Community Colleges Universities Vocational Schools

Which colleges are you interested in now? Which majors are you interested in now? Which careers are you interested in now?

What do you need assistance with to prepare for college? Check all that apply Students Grades 6-8 Only Academic Tutoring referral to tutorial services and online math tutoring. Academic Planning middle and high school graduation requirements. Pre-College Advisement benefits of a college education, college admission requirements, research college/university options, visit various colleges. Financial Aid Advisement information on federal aid programs and scholarships. Financial and Economic Literacy introductory information on budgeting, savings, credit and debt. Career Exploration research careers, visit job sites, and tour colleges. Study Skills test taking strategies, time management, note taking skills Life Skills goal setting, conflict resolution, self-esteem. Visit College Campuses & Cultural Enrichment- Exposure to colleges/universities and cultural events (e.g. theater, museum tours) Computer Technology computer use and assistance, internet use and safety, online college and scholarship research, supplemental learning software available.

What do you need assistance with to prepare for college? Check all that apply Students Grades 9-12 Only
Academic Tutoring referral to tutorial services and online math tutoring. Academic Planning high school graduation requirements, A-G college admission requirements (rigorous curriculum courses). Pre-College Advisement benefits of a college education, college admission requirements, research college/university options, visit various colleges/universities, assistance completing community college, CSU, UC, Private, and out-of-state applications. Financial Aid Advisement information on federal aid programs, assistance completing the Free Application for Federal Student Aid (FAFSA) and scholarship research. Financial Literacy information on budgeting, savings, credit and debt. Career Exploration research careers, visit job sites, and tour colleges. Study Skills test taking strategies, time management, note taking skills Life Skills goal setting, conflict resolution, self-esteem. Visit College Campuses & Cultural Enrichment- Exposure to colleges/universities and cultural events (e.g. theater, museum tours)

 Student Leadership engage in leadership skill development through membership in the Talent Search club and complete community service projects.

Computer Technology computer use and assistance, internet use and safety, online college and scholarship research, supplemental learning software available. Student Leadership engage in leadership skill development through membership in the Talent Search club and complete community service projects