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ETS Application

Student Information
* Last Name
* First Name
* MI
* Social Security Number
* Street Address
* City
* State
* Zip
* Gender
* Birth Date
* Age
* Telephone Number
* Email Address
* Do you have a documented disability?
* Is English the primary language spoken in your home?
* Ethnicity
Educational Information
* What grade are you in now?
* What school are you currently attending?
* What year do you plan to graduate from high school?
Citizenship Information
* Are you a citizen or permanent resident of the United States?
Family Information
The following information is kept confidential and REQUIRED to be eligible for the ETS program. Educational Talent Search is a federally funded program that requires verification of every participant’s family income and parent’s education level.
* Parent/Guardian's Name:
* With whom does the student live?
* The following line numbers correspond to taxable income. Please review your particular federal form for the following information. We must have this information to process your application.
Which tax form did you use?
* How many people live in your house including yourself?
* Student's natural / adoptive father:
* Student's natural / adoptive mother:
Medical Information
* Emergency Contact:
* Relationship:
Address of Emergency Contact
* Street
* City
* State
* Zip
* Phone
Alternate Phone
* Family or Primary Physician
* Phone
* Do you have any chronic illnesses?
* Are you allergic to any foods or medications?
* Please list any medication you are currently taking
I agree to accept the following responsibilities in order to remain an active participant of the ETS program:
  1. My purpose will be to graduate from the secondary education system and prepare for entrance into a post-secondary educational program at a college, university, or technical/trade school.
  2. I will be an active participant of the Educational Talent Search Program and commit to a minimum of two meetings with ETS staff, attendance at ETS workshops, campus visits/cultural events, group or one-on-one tutoring sessions, academic advising, career or personal counseling sessions, or participation in the summer learning academy.
  3. I will complete all required application/update forms, student assessments and evaluation forms for participation in the ETS program.
  4. I will permit ETS staff access to my grade reports, financial aid documentation, and other confidential records necessary for program documentation and evaluation. I will also participate in developing an Individual Plan of Action for myself to assist in achievement of my personal goals.
  5. I understand that it is the goal of ETS staff to support my educational goals and that I am encouraged to seek help from them at any time.
  6. I will abide by all rules and policies of the ETS program at all times.
I would like to participate in the Missouri Southern State University Talent Search Program and receive the free services and benefits provided, and I agree to the above responsibilities.
* Student Signature (Typing your name constitutes a signature)
Parent/Guardian: Please review this application to be sure that everything is complete and accurate.

I grant permission for my child to participate in the Missouri Southern State University Educational Talent Search program and receive the free services and benefits provided. I hereby certify that the information provided on this application is correct. I authorize any school, college, or other educational institution to release academic and/or financial aid records or other educational records to the Educational Talent Search program at Missouri Southern State University to assist with my child’s educational goals. I further give permission for Talent Search to take photos of the educational activities in which my child may be participating for the purpose of promotional activities and/or ETS newsletters. In case of emergency procedures, I authorize Educational Talent Search staff to use their discretion regarding the college’s emergency procedures. I will not, in any way, hold MSSU or Educational Talent Search responsible for any treatment deemed necessary, medical or otherwise. The medical information on this form will only be used in case of emergency.
* Parent/Guardian's Signature (Typing your name constitutes a signature)