School
Drop Box Office
Gompers
Bret Harte
Henry Clay
Locke H.S.
Washington Prep H.S.
Attendance
Attendance
Counseling
Counseling
College Office
LOS ANGELES SOUTHWEST COLLEGE
1600 W. Imperial Hwy., Los Angeles, CA 90047
(323) 242-5523 Office or (323) 242-5524
Educational Talent Search
(Blue or Black Ink Only)
Application for Services
Student Information
Legal Name _____________________________ _______________________________
(Last)
(First)
______________________________
(Middle) (Nickname, if any)
Social Security Number _______- _____-_______ E-mail address: __________________________________
Mailing Address (primary) __________________________________________
________________________
City/ Zip
Telephone Number (_____) _____________________Alt. /Cell Number: (____) ______________________
Sex:
□Male □Female
Date of Birth _________________Place of Birth _______________________
Ethnicity: □African American □Hispanic □Caucasian □Native American □ Pacific Islander or □ other: ________________
Are you a (check one):
US Citizen □
Permanent Resident □
In Process □ other (specify) □ __________________ Are you an ESL student? □ yes □ no
Name of School _________________________________ Current Grade ________ GPA ________
(Bret Harte, Gompers, Henry Clay, Locke, Washington Prep)
Do you participate in any of the following programs: □ MESA □ MedCore or □Another Talent Search □ Upward Bound/Veterans or
Math and Science; □ any others
Who referred you to this program? Name: _________________________ Title: ___________________________
Parent/Guardian Information
Name _____________________________Relationship __________________________
______________________________
Highest Educational Level (high school, college)
Phone Number: (_____) ____________________
Work: (_____) ___________________ Cell: (_____) ___________________
Name ____________________________ Relationship __________________________ ______________________________
Highest Educational Level (high school, college)
Phone Number: (_____) ____________________
Work: (_____) _________________ Cell: (_____)___________________
In case of an emergency and we are unable to contact you, who should we contact?
Name: _______________________ Relationship: _________________ Phone number: _________________
Academic Need
Please check below the services that you believe would help your child achieve academic and personal success.
I think that my child will benefit from Educational Talent Search for the following reasons: (check all that apply)
____
Poor grades and/or test scores
____
Develop study and/or test-taking skills
____
Absenteeism/truancy/tardiness/expulsion
____
Exposure to educational options and opportunities
____
Help with personal and social skills/development
____
Interaction with other students and Talent Search staff
We encourage parental support and participation in program activities. Please indicate your willingness to help with these activities.
Check all interests: □ Be a Chaperone on a Field Trip
□ Be an Interpreter □ Be a Guest Speaker □ Assist with special functions
□ Donations, Time, □ Organize an Event, □ Plan an Excursion □ Plan parent advisory board meeting(s) or □ Disseminate information.
Educational Goals/Plan
*Complete High School (successfully)
*Apply for Financial Aid and Scholarships
*Apply for Housing at the Colleges of my choice
*Apply to at least three (3) College(s) A._____________________________B.________________________C. ________________________
*Choose at least three (3) Career Choice(s) A. _________________________ B.________________________ C. _________________________
Educational Talent Search
Program Eligibility Information
All information provided will be held in strict confidence and is necessary to determine student eligibility for program services.
We are required by the United States Department of Education to obtain income verification from all students served by the Educational Talent Search
program. This information is used to determine student eligibility for program services. Student financial and educational records are protected by the
Privacy Act of 1974. The U.S. Department of Education has the authority to gather such information (20 USC 1231a).
Number of persons currently living in the household: _______
Please check one statement of income:
Annual Income: _____ 0 - $15,600 _____ $15,600 - $21,000 ____$21,000 - $26,400 _____ $26,400 - $31,800 ___ $31,800 - $37,200
_____$37,200 - $42,600 ____$42,600 - $48,000 ____ $48,000 - $53,400 _____ $53, 400 and over
*Please check and attach one of the following: __W2 __AFDC __Public Assistance __Ward/Dependent __Unemployed ___ other: _______________
1040 1099 1040A
Educational Talent Search
Program Contract
Student Contract –“My goal is to graduate from high school and go to college.”
Educational Talent Search agrees to provide you with the programs and services that will enable you to be successful in your quest for higher education.
I agree to:
1.
2.
3.
4.
5.
6.
7.
8.
Strive for academic success.
Attend workshops or tutoring sessions that will help me achieve academic success.
Participate in program activities throughout the year.
Seek help from my school counselor or Talent Search educational advisor in selecting academic courses required for an education beyond high
school.
Attend school regularly.
Notify Talent Search educational advisor if I am suspended, expelled or receive school disciplinary action.
Contact Talent Search educational advisor if my class schedule changes.
Follow the steps necessary to be eligible for acceptance to college.
Parent Contract- “My goal is to support and encourage my child to graduate from high school and go to college.”
In order for my child to participate in the Educational Talent Search program, I will:
1.
Immediately contact the Talent Search educational advisor if my child receives disciplinary action at school.
2.
Be involved with Educational Talent Search activities as much as possible.
3.
Attend Parent Workshops and events throughout the year, whenever possible.
4.
Notify the Educational Talent Search office of any home address or phone number changes.
Student Signature __________________________
Date________________
Parent Signature ___________________________
Date ________________
Los Angeles Southwest College
Educational Talent Search
Consent Form
I, ________________________________ give my consent to the Educational Talent Search Program at Los Angeles Southwest College to access my
child’s school records, visit the classrooms and meet with my child, in order to secure and review any information that may be needed to verify program
eligibility, family income, academic progress and to complete applications to secondary/post-secondary institutions and financial aid programs. I
understand that (Student’s Name) ___________________________________, records will only be used by the ETS program. I also understand that
compiled records on a group basis may include any an all of these records. Information will be used to meet Federal Regulations, Evaluations, Annual
Reports and Cross-References to other TRiO/Community Base Organizations. This information will be held in the strictest of confidence.
My Child currently attends, ____________________________ Grade ________ Date: ______________
My Child currently attends, ____________________________ Grade ________ Date: ______________
*Parent/Guardian Signature: ____________________________
FOR OFFICE USE ONLY: Eligibility: □ Low Income □ First Generation □ Both □ Other Reviewed by__________ Advisor Approved by: ___________Coordinator