CONFIDENTIAL FAMILY INCOME AND INFORMATION
You must complete all portions of this application to be considered for eligibility
Number of people living in household: __________________________ (including students away at college)
My child is a participant in the free or reduced school lunch program ________Yes ________No
Did the family file a federal income tax report last year? ____________Yes ____________No
(If YES, complete Section A below left. If NO, Complete Section B, below right)
SECTION A:
Family Size Taxable Income
(refer to “Taxable Income” line on tax form)
_________1 $0 - $19,140 ________
_________2 $19,141 - $25,360 ________
_________3 $25,361 - $32,580 ________
_________4 $32,581 - $39,300 ________
_________5 $39,301 - $46,020 ________
_________6 $46,021 - $52,740 ________
_________7 $52,741 - $59,460 ________
_________8 $59,461 - $66,180 ________
SECTION B:
Complete this side if family did not
file a federal income tax report for
last year.
Check all sources of income:
_______SOCIAL SECURITY
_______CHILD SUPPORT
_______FOSTER CARE SUPPORT
_______SOCIAL SERVICES (TANF
OR OTHER)
_______ALIMONY
_______DISABILITY
_______VETERAN BENEFITS
_______OTHER (please specify)
PERTINENT INFORMATION and MEDICAL RELEASE
Information Release: I/we authorize Educational Talent Search (ETS) 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 scores, and school lunch program eligibility. I/we authorize ETS to obtain information related to my child’s
application for him/her to participate in the Educational Talent Search Program. I/we authorize ETS to obtain information from any agency or program providing
supplemental services. I/We have answered all questions on the ETS student and parent application forms to the best of our knowledge. I/We would like to be part of
the ETS program. I/We hereby give my permission for my child to participate in all Educational Talent Search activities. In addition, I hereby give my permission for my
child’s name, photograph, work, and/or statements to be used by Educational Talent Search for promotional, publicity, or instructional purposes.
Parent Initials_____________________ Date: ______________________
Medical Release: I do hereby grant permission to the Educational Talent Search Program (ETS) at Coahoma Community College and its authorized representatives, to
furnish emergency 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
and other authorized activities. This permission is conditioned 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 treatment as may be necessary for
the best interest of my child.
Parent Initials_______________________ Emergency Phone _______________________________ Date ____________________
PARENTS: I certify that the information on this form and any attachments are true, complete and accurate to the best of my
knowledge.
Parent/Guardian Signature________________________________ Date _________________________________
Coahoma Community College is an equal opportunity institution in accordance with civil rights and does not discriminate on the basis of race, color, national
origin, sex, disability, age, or other factors prohibited by law in any of its educational programs, activities and employment opportunities. The following
person has been designated to handle inquiries regarding the nondiscrimination policies: Michael Houston, Director of Human Resources/Coordinator for
504/ADA, Title IX Compliance Officer, Office #A100, Vivian M. Presley Administration Building, (662) 621-4853, mhouston@coahomacc.edu.
THIS AREA IS FOR EDUCATIONAL TALENT SEARCH STAFF AND OFFICE USE ONLY
Date application rec’d in office_______________ Date approved _______________Returned for completion____________________ Completed & approved _____________
Student withdrawal: Transferred to another school_______________ Completed Junior High School________________ Completed High School _________________
Dropped out of school ________________________ Dropped out of ETS Program __________________
LI/FG_________ LI only_________ FG only___________ Other________
