ETS Application Checklist

ETS Application Checklist
 Complete ETS application *Black Ink Only*
 Copy of parents’ most recent income taxes- SIGNED & DATED
 Copy of students’ Social Security card- SIGNED & DATED
Please, make sure all documents are completed before
turning in your application. If you have any questions you
may contact your site Program Assistant or call our ETS
office at 760-744-1150 ext. 8130.
Thank you!
Aplicación ETS- Lista de verificación
 Aplicación completa *tinta negra*
 Copia de sus impuestos mas recientes - firmada y fechada
 Copia de la tarjeta de Seguro Social de su estudiante - firmada y
fechada
Por favor, asegúrese que todos los documentos necesarios
estén completos antes de entregar su aplicación. Si tiene
alguna pregunta contacte a su Asistente de Programa o
llámenos a nuestra oficina al número 760-744-1150 ext. 8130.
Gracias!
1
Palomar College
Educational Talent Search Application
Step 1: Student Information
Please answer the following questions:
1. Name:
____________________________________________________________ Student ID # ___________________
Last
First
2. School Attending:
Middle Initial
DDMS
3. Current Grade Level:
8th
HVMS
9th
MMS
10th
EHS
11th
4. Mailing Address:
________________________________________________
OGHS
Graduating H.S. in: 20_____
12th
______________________
Street
Apt. #
_____________________ ___________________ ____________________
City
State
Zip
5. Home Phone #: (____) ________________ Cell Phone #: (____) _________________
6. E-mail Address: _________________________________________
7. Date of Birth _______-________-_____________
8. Gender:
Yes
9. Is the student Hispanic or Latino?
Female
Male
No
10. What race do you identify with? (Please check all that apply)
American Indian or Alaskan Native
Native African or African American
Native Hawaiian/Pacific Islander
Caucasian (white)
Asian American or Asian
Other: _________________________
11. What is the primary language spoken at home? _____________________________
12. With whom do you live?
Both Parents
Mother only
Father only
Other: _________________
13. Check all programs you are presently a participant of or are currently applying to.
AVID
Upward Bound CSUSM
ETS WAHUPA
Upward Bound
Citizenship
ETS is funded by the U.S. Department of Education. Regulations require that to
participate, an individual must be a U.S. citizen/national or a permanent resident of the U.S.
Are you a U.S. citizen or national?
Yes
No
Social Security Number: ______-_____-__________
If no, are you a parmanent resident of the U.S.?
Yes
No
Alien Registration Card #: _____________________ *required*
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.
1
Colegio Palomar
Solicitúd de Educational Talent Search
Paso 1: Información del Estudiante
Favor de contestar las siguientes preguntas:
1. Nombre:
________________________________________________ #de identificación del Estudiante:_____________
2. Escuela que está atendiendo:
3. Grado:
Inicial
Apellido
Primer nombre
8th
9th
DDMS
10th
HVMS
11th
MMS
EHS
OGHS
Graduating H.S. in: 20_____
12th
4. Dirección:
________________________________________________
______________________
Calle
Apt. #
_____________________ ___________________ ____________________
Ciudad
Estado
Correo Postal
5. Teléfono de Casa #: (____) ________________ Teléfono Celular #:(____) _________________
6.Correo Electrónico: _________________________________________
7. Fecha de Nacimiento: _______-________-_____________
9. ¿El solicitante es Hispano o Latino?
Sí
8. Sexo:
Femenino
Masculino
No
10. ¿Con que raza te identificas? (Por favor seleccione todos los que apliquen)
Indio americano o Nativo de Alaska
Africano Americano o Africano Nativo
Hawaiano Nativo o de las Islas del Pacifico
Anglo Americano
Asiático o Asiático Americano
Otro: _________________________
11. ¿Cuál es el lenguaje primario que hablan en casa?____________________________
12. ¿Con quién vives?
Ambos Padres
Solamente la Madre
Solamente el Padre
Otro: _________________
13. ¿En este momento estas participando o aplicando a uno de estos programas?
AVID
Upward Bound CSUSM
ETS WAHUPA
Upward Bound
Ciudadanía
ETS es financiado por el departamento de educación de los Estados Unidos. Regulaciones requieren que
para participar, El individuo debe ser ciudadano americano o residente permanente de los Estados Unidos.
¿Eres ciudadano Americano o nacional?
Sí
No
Número de Seguro Social: ______-_____-__________
¿Si no, usted es residente permanente?
Sí
No
Tarjeta de registro de extranjero #: _____________________*requerido*
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.
2
Palomar College
Educational Talent Search Application
Step 2: Parents/Guardian Information
MOTHER/GUARDIAN INFORMATION
1. Name of Mother/Guardian: ___________________________________________
2. Home Phone: (___)____ ______ 3. Cell Phone: (___)____ ______
4. Work Phone: (___)____ ______
5. Mailing Address:
________________________________________________
Street
____________________
Apt. #
_____________________ ___________________ ____________________
City
State
Zip
6. Email: __________________________ 7. Occupation: ________________________
Is the Mother/Guardian currently:
Employed
Unemployed
Disabled
Deceased
Retired
FATHER/GUARDIAN INFORMATION
1. Name of Father/Guardian: ___________________________________________
2. Home Phone: (___)____ ______ 3. Cell Phone: (___)____ ______
4. Work Phone: (___)____ ______
5. Mailing Address:
________________________________________________
Street
____________________
Apt. #
_____________________ ___________________ ____________________
City
State
Zip
6. Email: __________________________ 7. Occupation: ________________________
Is the Father/Guardian currently:
Employed
Unemployed
Disabled
Deceased
Retired
PARENT EDUCATION INFORMATION
To be eligible as a first generation student, neither of your parents/guardians can possess a bachelor’s
degree (also known as a “four- year degree”).
Please circle the highest grade level completed by each parent/guardian
Elementary
High School Diploma
College Degree
Mother/Guardian
1
2
3
4
5
6
7
8
9
10
11
12
Yes
No
1
2
3
4
Yes
No
Father/Guardian
1
2
3
4
5
6
7
8
9
10
11
12
Yes
No
1
2
3
4
Yes
No
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.
2
Colegio Palomar
Solicitúd de Educational Talent Search
Paso 2: Información de los Padres o Guardián
Información de la madre o guardián
1. Nombre de la Madre o Guardián:___________________________________________
2. Teléfono de Casa: (___)____ ______ 3. Teléfono Celular: (___)____ ______
4. Teléfono de Trabajo: (___)____ ______
5. Dirección:
________________________________________________
Calle
____________________
Apt. #
_____________________ ___________________ ____________________
Ciudad
Estado
Código Postal
6.Correo Electrónico: __________________________ 7. Ocupación: ________________________
La Madre o Guardián actualmente esta:
Empleada
Desempleada
Deshabilitada
fallecida
Retirada
Información del Padre o guardián
1. Nombre de la Padre o Guardián: ___________________________________________
2. Teléfono de Casa: (___)____ ______ 3. Teléfono Celular: (___)____ ______
4. Teléfono de Trabajo:(___)____ ______
5. Dirección:
________________________________________________
Calle
____________________
Apt. #
_____________________ ___________________ ____________________
Ciudad
Estado
Código Postal
6.Correo Electrónico: __________________________ 7. Ocupación: ________________________
La Padre o Guardián actualmente esta:
Empleada
Desempleada
Deshabilitada
fallecida
Retirada
Información de la educación de los padres
Para ser elegible como un estudiante de primera generación, ninguno de tus padres deben poseer un
bachillerato (también conocido como un “título de 4 años”).
Favor circule el nivel mas alto de educación recibida por cada padre/guardián.
Elementaría
Preparatoria Diploma
Colegio Titulo
Madre
1
2
3
4
5
6
7
8
9
10
11
12
Sí
No
1
2
3
4
Sí
No
Padre
1
2
3
4
5
6
7
8
9
10
11
12
Sí
No
1
2
3
4
Sí
No
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.
3
Palomar College
Educational Talent Search Application
Step 3: Release of Information
Student Information Release
Information provided to ETS is confidential and will not be released without the student’s premission. By signing below, you
authroize ETS to receive and release information to/from all applicable educational and career institutions to assist you in your
educational planning, verify enrollment, and secure financial aid opportunities for program participants. In addition, your
information may be released to the Department of Education to demonstrate program effectiveness when requesting
renewed funding.
The information requested below will be utilized to assist in providing services to you. In order to provide the most effective
services, we may need to obtain information from several sources; such as high schools, colleges, testing agencies, counselors,
admissions and financial aid officers, social workers, etc. ALL THE INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL
IN COMPLIANCE WITH THE FAMILY RIGHTS AND PRIVACY ACT.
Request a copy of my middle school/high schoool/ and or college transcript, test scores, and or documentation of grades
Request a copy of my test scrore reports (STAR/CST, ACT, SAT) from the American College Testing Program, College Board, and Educational Testing Services
Communicate with representatives from the agencies or post-secondary institutions on my behalf.
In addition, I verify that the information provided in this application is true and accurate.
______________________________________________________________ __________________________________
Date
Parent Signature
Photo/Media Release
Much of our publication and marketing success is from the use of photos and videos taken of ETS students during program
events. By signing below, you give the irrevocable right to use your name, photo, or video in all forms and media and in all
manners, including composite or distorted representations, for advertising, trade or any other lawful purposes, and you waive any
right to inspect or approve the finished version(s), including written copy that may be created in connection therewith. I have
read this release and am fully familiar with the contents.
______________________________________________________________ _________________________________
Parent Signature
Date
FOR OFFICE USE ONLY
Total Taxible family income (line 43 on the 1040 form, line 27 on the 1040A form and line 6 for the 1040EZ form)
reported on Federal Income Tax Return during the most recent tas year is: $ ___________________________________
Total number of people supported by this income is: _____________________.
The 20____ federal TRIO programs annual low-income
Level for a family unit with __________ members is:
$
,
Eligibility:
LI & FG
LI ONLY
FG ONLY
DI ONLY
LI & DI
Date of application entry in Blumen ____________ Initials of data entry staff _______
Current overall GPA on transcript ____________ CAHSEE MATH ___________ CAHSEE ELA___________
Approved/accepted
Not recommended/Denied
Reason: ___________________________
___________________________________________________
Director Signature
Date
___________________________________________________
Supervisor Signature
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.
Date
3
Colegio Palomar
Solicitúd de Educational Talent Search
Paso 3: Divulgación de Información
Divulgación de información del estudiante
Información proveída a ETS es confidencial y no será divulgada sin la autorización del estudiante. Al firmar, autoriza a ETS a recibir
y dar información a todas las instituciones educativas para que ayuden en la planeación educativa, verificar inscripciones, y
asegurar oportunidades de ayuda financiera para los participantes del programa. Además, la información puede ser divulgada al
departamento de educación para demonstrar la efectividad del programa al solicitar nuevos fondos.
La información requerida va a ser utilizada para ayudarnos en proveer servicio para ti. Para poder proveer en servicio más adecuado y efectivo, necesitamos obtener información de diferentes fuentes como la preparatoria, colegios, agencias de exámenes,
consejeros, oficiales de admisión y ayuda financiera, trabajadores sociales, etc. Toda la información recibida se mantendrá
confidencial con el acatamiento de los derechos de familia y la ley de privacidad.
Requerimos una copia de transcripciones de la secundaria o preparatoria y/o del colegio, resultados de exámenes y/o documentación de grados.
Requerimos una copia del resultado de los exámenes (STAR/CST, ACT, SAT) de American college testing, College Board, y Educational Testing Service.
Comunicarse con representativos de agencias o instituciones post-secundarias en mi nombre.
Además, yo verifico que la información proveída en esta solicitud es verdadera y correcta
______________________________________________________________ __________________________________
Firma del Padre
Fecha
Uso de fotografías e imágenes:
Gran parte de nuestra publicación y éxito de la comercialización es a partir de la utilización de fotos y videos tomados de los
estudiantes de ETS durante los eventos del programa. Al firmar a continuación, nos da el derecho irrevocable a usar su nombre,
foto o video en todas las formas y medios de comunicación y de todas las maneras, incluidas las representaciones arregladas o
alteradas, con fines publicitarios, comerciales o cualquier otro propósito legal, y usted renuncia a cualquier derecho a inspeccionar o aprobar la versión final (s), incluyendo copias impresas que se pueden crear en relación con ellos. He leído esta nota y estoy
plenamente familiarizado con el contenido.
______________________________________________________________ _________________________________
Firma del Padre
Fecha
FOR OFFICE USE ONLY
Total Taxible family income (line 43 on the 1040 form, line 27 on the 1040A form and line 6 for the 1040EZ form)
reported on Federal Income Tax Return during the most recent tas year is: $ ___________________________________
Total number of people supported by this income is: _____________________.
The 20____ federal TRIO programs annual low-income
Level for a family unit with __________ members is:
$
,
Eligibility:
LI & FG
LI ONLY
FG ONLY
DI ONLY
LI & DI
Date of application entry in Blumen ____________ Initials of data entry staff _______
Current overall GPA on transcript ____________ CAHSEE MATH ___________ CAHSEE ELA___________
Approved/accepted
Not recommended/Denied
Reason: ___________________________
___________________________________________________
Director Signature
Date
___________________________________________________
Supervisor Signature
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.
Date
Palomar College
Educational Talent Search Application
4
Step 4: Teacher/Counselor Recommendation Form
___________________________________is applying for admission to the Palomar College Educational
Talent Search (ETS) program. ETS serves students from 8th to 12th in participating target schools. We are
interested in applicants who wish to pursue a post-secondary education. We greatly appreciate your input
on this student’s academic performance and dedication.
Teacher/Counselor name:
_______________________________________________________________
First
School:
Last
DDMS
HVMS
MMS
EHS
OGHS
Please answer the following questions about this student.
Has this student demonstrated interest obtaining a post-secondary education?
Yes
No
Please check the areas in which you feel that the ETS program could help the student:
Post-secondary planning and selection
Financial aid assistance
College entrance exams
Career awareness
Academic skills
Please rate the student in the following area (5 being excellent and 1 being below average)
5
4
3
2
1
1. Leadership:
5
4
3
2
1
2. Dependability:
5
4
3
2
1
3. Confidence:
5
4
3
2
1
4. Work Ethic:
5
4
3
2
1
5. Attitude:
Comments: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________
________________________________________________
Counselor/teacher Signature
_________________________________
Date
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.
Colegio Palomar
Solicitúd de Educational Talent Search
4
Step 4: Teacher/Counselor Recommendation Form
___________________________________is applying for admission to the Palomar College Educational
Talent Search (ETS) program. ETS serves students from 8th to 12th in participating target schools. We are
interested in applicants who wish to pursue a post-secondary education. We greatly appreciate your input
on this student’s academic performance and dedication.
Teacher/Counselor name:
_______________________________________________________________
First
School:
Last
DDMS
HVMS
MMS
EHS
OGHS
Please answer the following questions about this student.
Has this student demonstrated interest obtaining a post-secondary education?
Yes
No
Please check the areas in which you feel that the ETS program could help the student:
Post-secondary planning and selection
Financial aid assistance
College entrance exams
Career awareness
Academic skills
Please rate the student in the following area (5 being excellent and 1 being below average)
5
4
3
2
1
1. Leadership:
5
4
3
2
1
2. Dependability:
5
4
3
2
1
3. Confidence:
5
4
3
2
1
4. Work Ethic:
5
4
3
2
1
5. Attitude:
Comments: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________
________________________________________________
Counselor/teacher Signature
_________________________________
Date
Admission to the Palomar Community ETS Program is open to those who meet the eligibility
criteria, regardless of gender, race, national origin, age, religion, or disability. For more
information, call (760) 744-1150 ext. 8130 or 8131
The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.