Fillable 2013 2014 Ets Application (Bluegrass Community and Technical College)

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2013 2014 Ets Application (Bluegrass Community and Technical College)

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164 Opportunity Way, Lexington KY 40511
Phone 859.246.6574 Fax 859.246.4656
Educational Talent Search
Application 2013-2014
Part I ~ Student Information
(please respond to each question)
Name _________________________________________________________________________________________ Date ________________
School _______________________________________________________________________________________________ Grade _______
Home Address _________________________________________________________________________________________________________
City ________________________________
, KY
ZIP ______________ Student Cell ______________________________________
Parent E-mail ___________________________________________________ Parent Cell ______________________________________
Student E-mail __________________________________________________ Date of Birth _______________ Gender (M/F) _____
Social Security Number
US Citizen (Y/N) _______ Free or reduced lunch program participant (Y/N) _______
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific islander
White
Two or more races
(plea se check oth er cat ego rie s a s ne ede d)
Part II ~ Parent/Guardian Information
(please resp ond to each question)
The student lives with (check one)
Both parents
One parent
Parent & step parent
Foster parent(s)
Legal guardian(s)
Other
Parent/Guardian Name(s)
Family’s 2012 Taxable Income
(check one)
_____________________________________________________________________________
_____________________________________________________________________________
Did either parent
graduate
from a four-year college? (Y/N) __________________________
If yes, name of college?_________________________________________________________
How many people are living in your household? _____________________________________
La st N ame Fir st Nam e M. I. Pr ef err ed Name
Str eet Apartment N um be r
La st N ame Fir st N am e Re lat ion
La st N ame Fir st N am e Re lat ion
Educational Talent Search is a federal TRIO Program funded by the United States Department of Education and
sponsored by Bluegrass Community and Technical College, an equal opportunity institution
CONTINUED ON PAGE TWO
Racial Background
From the
Taxable Income
line of 20 12
Federal Tax f orm (line 41 on f orm 104 0)
$17,235
and
under
$17,236 to
$23,265
$23,266 to
$29,295
$29,296 to
$35,325
$35,326 to
$41,355
$41,356 to
$47,385
$47,386 to
$53,415
$53,416 to
$59,445
$59,446 and
higher
164 Opportunity Way, Lexington KY 40511
Phone 859.246.6574 Fax 859.246.4656
X X
Part III ~ Interests and Activities
What are your favorite subjects in school?___________________________________________________________________________________________
______________________________________________________________________________________________________________________________
What are your extracurricular activities? ____________________________________________________________________________________________
______________________________________________________________________________________________________________________________
What is your least favorite subject in school? ________________________________________________________________________________________
______________________________________________________________________________________________________________________________
What are some areas of your school or personal life that you think we could help you to improve? ____________________________________________
______________________________________________________________________________________________________________________________
Are you interested in attending college or vocational school after high school?
Yes
Maybe
No
Would you be interested in attending field trips to colleges and universities?
Yes
Maybe
No
What goals have you set for yourself? ______________________________________________________________________________________________
Would you like to be a Talent Search participant? Why or why not? ______________________________________________________________________
Will you commit to attending monthly Educational Talent Search workshops at your school?
Yes
Maybe
No
Part IV ~ Academic Performance
Please include a copy of a recent
report card
with this application.
We cannot process your application without an official record of your academic performance.
Part V ~ Authorizations and Signatures
Authorization to Obtain and Utilize Images
~ It is the policy of Bluegrass Community and Technical College Educational Talent Search that informed written
consent be granted for all photography and/or videotaping.
By signing below,
the parent/guardian of the student applicant hereby grants permission to ETS to
photograph
and/or
videotape
either the adult parent/guardian or the minor child upon admission into ETS.
The parent/guardian also authorizes Bluegrass
Community and Technical College Educational Talent Search to use and/or permit others to use the aforementioned images in educational, informational and
promotional activities for ETS without compensation.
Authorization to Release Academic/Educational Information
~ The parent/guardian authorizes the student’s schools to release any academic/
educational information from the student’s files that are requested by Bluegrass Community and Technical College Educational Talent Search, and authorizes
ETS to release academic/educational information to assist in the student’s education.
I agree to the above statements, and certify that, to the best of my knowledge, all information provided herein is correct.
__________________________________________________________ __________________________________________________________
Part VI ~ Administrative Use Only
1. Date Received ______________________________________ 6. Exit Date _______________________________________
2.
LI
FG
LIFG 7. Exit Grade & School ______________________________
3. Status
ENROLL
WAIT LIST
DENY 8. Exit Advisor _____________________________________
4. Initial Advisor _______________________________________ 9. Exit Plans ______________________________________
5. Enrollment Date _____________________________________ _________________________________________________
Parent/Guardian Signature Date Student Signature Date
2013-2014
APPLICATION PAGE TWO ~ EDUCATIONAL TALENT SEARCH
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2013 2014 Ets Application (Bluegrass Community and Technical College)

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Completed 20 July 2020

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