EDUCATIONAL TALENT SEARCH PROGRAM
Southeastern Community College
A
pplication Release Form
2020-2021 School Year
Please print and fill out completely.
Date:
Grade:
School:
First Name
Middle Name
Last Name
Home Phone
Address
Cell Phone
City/State
Zip Code
Student email
Parent e-mail
Birth Date
Social Security No: (required)
Gender
Male
Female
US Citizen
Yes
No
Race
African American/Black
Asian/Pacific
Islander
Caucasian/White
Hispanic
Native American
Multiracial
Other (specify) ________________________________
With whom do you live?
Both Parents
One Parent
Parent and
Stepparent
Adoptive
Parent(s)
Grandparents
Foster Parents
Other (specify)
Father/Guardian Name
Job
Mother/Guardian Name
Job
Did either parent graduate from a 4-year college?
Yes
No
College Name
Parent or Guardian must complete
Check the box that indicates family taxable income (after deduction):
$18,735 or below
$18,736 – 25,365
$25,366– 31,995
$31,996 – 38,625
$38,626 - 45,255
$45,25651,885
$51,886 - 58,515
$58,516 - 65,145
$65,146or above
Check any of the following from which you receive assistance:
School Lunch
Social Security
AFDC
Disability
Food Stamps
Medicaid
Other (specify) ________________________________________
Total number living in household: _________
PERMISSION FOR ACCESS TO EDUCATIONAL RECORDS
I hereby give permission for the Educational Talent Search Program to have access to any educational records which
are needed for full program services. I also give permission to the postsecondary institution I attend to release
admission and financial award information to the SCC Educational Talent Search Program. I grant SCC permission
to reprint my child's photograph for publication, website, electronic and digital media, publicity, and advertising.
Date
Student Signature
Date
Parent/Guardian Signature
click to sign
signature
click to edit
click to sign
signature
click to edit
EDUCATIONAL TALENT SEARCH PROGRAM
Southeastern Community College
Application Release Form
2020-2021 School Year
Individual Education Plan
EXPECTED GRADUATION DATE: ___________________________
What are your plans after high school? Checkbox
Four-year college
Community College
Get a job
Join Military
Undecided
Other
What colleges are you interested in attending? 3 fill-in options
1. ________________________________
2. ________________________________
3. ________________________________
What college campuses have you visited? 3 fill-in options
1. ________________________________
2. ________________________________
3. ________________________________
In what extra-curricular activities have you participated?
Have you taken the SAT?
Yes
No
If yes, what was your composite score?
Score:
Do you plan to take the SAT?
Yes
No
Have you taken the ACT?
Yes
No
If yes, what was your composite score?
Score:
Do you plan to take the ACT?
Yes
No
What are your hobbies?
What are your favorite subjects?
Please list any subject(s) in which you are experiencing trouble/poor grades.
Educational Talent Search Program offers the following services:
(Please check any you need help with)
Career Information
College Information/Tours
Financial Aid Information
Scholarship Information
Academic/Career Counseling
Tutoring (List Subject)
College Application Assistance
Financial Aid Application Assistance
Personal Counseling
Study Skills Information
Other (specify)
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome