ANNE ARUNDEL COMMUNITY COLLEGE EDUCATIONAL TALENT SEARCH PROGRAM APPLICATION CERTIFICATION

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					                           ANNE ARUNDEL COMMUNITY COLLEGE EDUCATIONAL TALENT SEARCH PROGRAM
                APPLICATION/CERTIFICATION OF ELIGIBILITY FORM--101 N. CRAIN HWY.; GLEN BURNIE, MD 21061; (410) 777-2814
I.       Applicant/Student Information (Please Print or Type)

Name (Last):                                        (First):                                         (MI):           Student’s Social Security No:                     -           -

Address (Street):                                                                                     (City):                                 (State):______ (Zip):

Home Telephone: (               )                                    Other Phone:                                                    Gender:         ____ Male         ____ Female
CHECK ONE : _____ American Indian/Alaska Native      _____ Hispanic/Latino                                                    _____ Caucasian (White)               _____ Asian
            _____ Native Hawaiian/Pacific Islander _____ African American (Black)                                             _____ More than one race

Date of Birth:________________ Age: ____ Are you a U.S. Citizen?                               Yes        No      If no, are you a permanent resident?               Yes      No
Alien Registration #:                                                                   E-mail address:

Language spoken in your home/with friends:                                                    Are you limited in your ability to speak / write English?                Yes     No

Current School:                                                               Current Grade: _______              Number of Siblings:

Number of family members living in household: _______
Are you currently involved in school clubs, organizations, sports or community activities?                              Yes       No        If yes, please list:


What are your interests and hobbies?
Future Plans?
II. Parent/Guardian Information: Student resides with                        ___ Parent(s);       ____ Legal guardian;          ____ Foster parent;           ____ Other:
A.        Applicant’s Father/Stepfather or Guardian’s Name (if living in the household):

Work Phone: (               )                                  If legal guardian what is your relationship to the applicant:
Highest grade completed ____:               Diploma ___;        GED ___; Some College ___;                  Assoc. Degree ___; Bachelors ___;                  Masters ___; Ph.D. ___
B. Applicant Mother/Stepmother or Guardian’s Name (if living in the household):

Work Phone: (               )                                  If legal guardian what is your relationship to the applicant:
Highest grade completed ____;               Diploma ___;        GED ___; Some College ___;                  Assoc. Degree ___; Bachelors ___;                  Masters ___; Ph.D. ___
C. Have you applied for free/reduced lunch?                  Yes        No     Does your child receive free lunch?                 Yes       No Reduced lunch?               Yes       No
Did you file a federal income tax return last year?                       Yes (check the income level that applies below)                   No (use the attached income
worksheet)

III Please check the income level that applies to the applicant’s family taxable income for last year. Income information is required by the
U.S. Department of Education to verify program eligibility.

___ $0-$15,315                      ___$15,316-$20,535                ___$20,536-25,755                  ___$25,756-30,975                  ___$30,976-36,195
___$36,196-41,415                   ___$41,416-$46,635                ___$46,636-$51,855                 ___$51,856 and up

I certify that all information in this document is true and complete. I give my permission for my child to participate in the Educational Talent Search
Program. I give permission to have school/agency records released to ETS to include transcript, test and grade reports. Additionally, I give
permission to ETS to discuss my child’s/my academic progress with teachers and counselors. I understand that the information is confidential and
will be used for federal reporting purposes and to allow ETS to help my child/me meet educational goals.
Applicant/Student Signature:                                                                                                                            Date:

Parent or Guardian Signature (if applicant is under 18):                                                                                               Date:

For Office Use Only:                 Standard (2/3 Category)                                                     Non-Standard (1/3 Category)
                 Eligibility:        ____ LI & FG                                                   ____ LI only              ____ FG only             ____ Other
                 Counselor’s Initials: ________                Date Received: __ __________                      Date Processed: _____________
Director’s Approval:
                 Eligibility Approved For:        ___LI & FG               ___LI Only               ___FG Only                ___Other       ____ Wait List ____ Not Accepted
                 Program Date of Entry ___________________                 Director’s Signature ______________________________ Date: ______________
                                                    Educational Talent Search is funded by the United States Department of Education.
     Revised 9/22/06
                                    Anne Arundel Community College is an equal opportunity/affirmative action/title ix/ADA title 504 compliant institution.