I certify that the information I have provided is complete and correct to the best of my knowledge.
Century College Educational Talent Search has my permission to access the following information
for the purposes of determining program eligibility and the reasons specified; Transcripts/test scores
for advising purposes and to assess credits and graduation process; Class schedules to contact and
involve students in program services and activities; Enrollment data to verify target school attendance.
I also give permission for the use of my child’s name and/or photograph for editorial, promotional,
recruitment or educational purposes. I understand that I may withdraw permission to access
information at any time through written notification.
The “Release of Records” is essential and required in order for Century College ETS/TRiO
staff to gather student data for purpose of reporting to the U.S. Department of Education.
Therefore, I/we authorize ETS representatives to communicate with representatives from
postsecondary institutions on my behalf for up to six years post high school graduation. This also
authorizes the postsecondary institution in which said student is enrolled to release information about
admissions, college academic enrollment and degree completion.
This information is used for program reporting and verification of postsecondary completion. This
information is private and protected under the General Education Provision Act as well as the Family
Education Rights and Privacy Act.
Student Signature Date Parent or Guardian Signature Date
Print Student Name Print Parent or Guardian Name
Are you participating in another college access program? (circle all that apply)
Upward Bound AVID MEP College Possible Gear Up/Get Ready
Upward Bound-Math/Science Others:
Acceptance in the Educational Talent Search program is based on the number of available openings in the
program where the student attends school. All applicants will be notified of their status. Every effort is made to
accept students as openings occur.
An affirmative action, equal opportunity employer and educator.
This document can be available in alternative formats to individuals with disabilities by calling 651-779-3354 or 1-800-
228-1978 x3354 voice, 651-773-1715 TTY, or through the Minnesota Relay Service at 1-800-627-3529.
"A partnership between Century College and St. Paul Public Schools"
Educational Talent Search-TRiO Program is a federally funded program hosted by Century College.
It is designed to encourage students to complete middle/high school, and assist them in entering and
completing a postsecondary program of their choice. ETS is a FREE planning and resource service
for students who are interested in continuing their education beyond high school, but who may need
assistance in determining an appropriate school, program of study, or in maximizing their student
financial aid.
Two-thirds of participants are required to come from low-income and potential first-generation families
to go to college. The information gathered in this document is used for the purpose of assessing
eligibility, tracking student success and needs in the Educational Talent Search Program.
How to contact us: Educational Talent Search
Century College
3300 Century Ave N
White Bear Lake, MN 55110
651-779-3980 or 651-779-3967
Please complete entire application and have your student return it to his/her ETS Advisor at
school. (Legally, you are not required to provide the following information, however, ETS will not be
able to consider your application if sufficient information is not provided.)
*Yellow highlighted areas must be completed prior to acceptance.
All information is confidential and protected by the Family Educational Rights & Privacy Act and is not
specifically reported to the federal government or the U.S. Department of Education. However, the U.S.
Department of Education does have the authority to gather general statistical information about the program
participants in order to improve and measure the success of the Educational Talent Search Program.
First Last Middle
Address: Apt. #:
City: MN Zip Code: Date of Birth:
School: Current Grade: CIF#:
Please complete this application and return it to the ETS
Advisor in your school or to the ETS Office at:
3300 Century Avenue North, White Bear Lake, MN 55110.
If you have any questions, call (651) 779-3967.
click to sign
click to edit
click to sign
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Gender: Male:___ Female ___Age: Social Security #:
Home Phone: Cell:
Check box to opt out of texts
Student Email: Facebook Email Address:
RESIDENCE: The student lives with
Both parents (a) Foster home (e)
One parent father mother (b) Other (f)
Court Appointed Legal Guardian (d)
Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American,
or other Spanish culture, regardless of race) (d) please circle: yes no
Racial Background: (Select all the apply to you)
American Indian or Alaska Native (a person having origins in any of the original people of North and South
America, including Central America, who maintains cultural identification through tribal affiliation or community attachment) (a)
Asian (a person having origins in any of the original people of the Far East, Southeast Asia or the Indian subcontinent) (b)
Black or African American (a person having origins in any of the black racial groups of Africa) (c)
White (a person having origins in any of the original people of Europe, the Middle East or North Africa) (e)
Native Hawaiian or Other Pacific Islander (a person having origins in any of the original people of Hawaii, Guam,
Samoa, or other Pacific Islands) (f)
What is most often spoken in your home?
Are you a citizen of the USA? Yes No. If you answered “no” to this question, please
provide Your Permanent Resident Card Number:
Please check (
) which areas you feel more What is your average grade?
information or knowledge may help to improve A B C below C
your academic success or clarify your future goals?
a. Academic planning Please check (
) the statement(s) below that apply to you.
b. Career choices a. ____ I am undecided about my future plans after high school.
c. Career planning b. ____ I have no plans to continue my education after high school.
d. College planning c. ____ I plan to continue my education beyond high school at
e. College testing preparation a. a college or university
f. Financial aid information b. vocational school
g. GED programs c. apprenticeship
h. Self-esteem d. military
i. Study skills e. other
j. Test taking d. I do not plan to further my education, but plan to go to work.
k. Writing e. other
Name: Phone (W): Phone (Cell/H):
Address: City: State: Zip Code:
Email: Relationship:
Name: Phone (W): Phone (Cell/H):
Address: City: State: Zip Code:
email: Relationship:
Would you like to receive ETS emails? Yes_____ No______
Does either parent have a 4-year college degree? Yes No
Name of college where parent earned degree:
If yes, does student live with this parent most often? (Yes/No)
Name: Relationship: Phone:
Address: Apt. #:
City: State: Zip Code:
Financial Verification
Federal Grant Regulations require verification of income for all
applicants and must be completed!
Total number of people in household (include yourself):
Taxable Income for last year (from the most recent completed tax form)? $
(1040 line 37, 1040A line 21, and 1040EZ line 4)
Check if you did not file taxes (reason?):
Do you qualify for: Free Lunch_________ Reduced Lunch________
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