Thank you for your interest in our Educational Talent Search program!  ETS is a FREE, educational program for students 11-27 years old who have completed fifth grade.  ETS is deigned to assist participants in their preparation for enrollment into ANY college of their choice.  If you have any questions, please call our office at 1-800-527-4047.

Section 1: Student Information:
Last Name *
First Name *
Middle Initials
Gender *
Preferred Pronouns
School *
Grade *
Date of Birth *
Age *
Social Security #

**SS# requested for program purposes**

Student Cell Phone *
Student Email *
Is a language other than English spoken at home? *
If yes, which language?
Are you a current ELL participant? *
Mailing Address *
Address 2
City *
State *
ZIP Code *
Residency *
If you checked becoming a citizen or permanent resident of U.S. please provide you USCIS case number
Do you identify as: Hispanic/Latino *

Please choose the racial group(s) with which you most identify (even if you also identify as Hispanic/Latino). 

*Check yes to all that apply*

American Indian or Alaskan Native (American Indian includes origins in North, South, or Central America) *
Asian *
Black or African American *
Native Hawaiian/Pacific Islander *
White/Caucasian *

Section 2: Needs Section:
Please check the workshops and activities you believe will be helpful to you:
Academic Planning
ACT Preparation
Career Planning
College Information/Planning
Healthy Lifestyle Habits
Money Management
Are you currently participating in any of the following programs? (Please check all that apply)
AVID
Upward Bound
Science Bound
Gear Up
None
Do you want to go to college? *

Section 3: Student's Family Information:
With whom do you live with at the address listed above? *
If you selected Other, please specify
Please list their name(s):
Name *
Cell Phone *
Name
Cell Phone

Section 4: Parent Information-MUST be completed by the parent with whom you live more than half the time:
ETS is required to verify that our participants meet federal criteria based on educational background and family income level.  To determine eligibility for ETS benefits, please answer the following questions.  Questions refer to the parents' income and education level not the student, unless the student is independent.  This information is only used to verify the ETS program is serving eligible students, should we be audited.  This information well be kept confidential.
*If student resides in foster care or legal guardianship, please write or select NA in the required fields for this section*
Did he/she graduate from a 4-year college/university *
Gender *
Parent Email
Parent/Guardian Name *
Occupation
If yes, what college?
Parent/Guardian Name
Gender
Parent Email
Occupation
Did he/she graduate from a 4-year college/university?
If yes, which college?
ETS would like to keep you updated on events, newsletters and other materials occasionally (no more than one email per month).
Check this box if you DO NOT want to receive emails
Number of People in your family: Include all individuals in the family who are provided for, completely or more than 50%, by the family taxable income.  This includes college students age 21 or younger who may be living elsewhere while in school. 
Number of people in your family? *
Household Income Range (line 15 on 1040 tax form for 2020): *
Taxable Income: Taxable income from most recent taxes, income AFTER all deductions.  Refer to 2019 IRS tax form 1040 line 11b or the line that reads TAXABLE INCOME.
Do you receive SNAP benefits?
If you have a FIP Case # please provide
If you did not file a tax return, please list the parental yearly take home pay (including child support, social security, etc.)
Parent Signature *
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Signature: (Type in your full name)
I agree to the terms included.

Section 5: Consent and Signatures

Consent to Photograph or Videotape ETS Participants Engaged in Program Activities 

ETS occasionally photographs or makes digital/video recordings of ETS participants while involved in program activities.  These photos/videos my be used in programs newsletters, publications, informational brochures and presentations, recruiting meetings, and program web pages.  Photographs and video clips will NOT be sold or used in any for-profit publications or presentations.  Identifying information (such as names or home or school addresses) will NOT be included without first gaining the express consent of the student or his/her parent or legal guardian, if the student is under 18.

Does ETS have permission for photograph/videotape release? *
Parent/Guardian Signature *
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Signature: (Type in your full name)
I agree to the terms included.
Student Signature *
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Signature: (Type in your full name)
I agree to the terms included.

Release of Information: Academic Standing/Enrollment and Graduation Status

Student Permission:

I recognize ETS provides assistance to students preparing for and applying to postsecondary education programs and institutions.  I understand the U.S. Department of Education and Central College have an interest in assessing the effectiveness of ETS in providing these services.  I therefore consent to the release of information regarding my enrollment, financial aid, academic standing, and graduation status for my postsecondary institution, the National Student Clearinghouse, and/or state data system to Central College ETS.  I understand my social security number will be used only to ensure ETS accurately identifies me when tracking my progress through the online data systems.  I understand this information will be held in a confidential file and will be used only for the reporting purposes described above.

This release shall remain in effect for seven twelve-moth periods (7 years) beyond the date of my planned graduation from high school.  I understand that if I am not admitted to the program, this release shall be immediately null and void.  I understand I may revoke this release at any time by submitting to Central College ETS a dated written statement denying the release of the above information. 

Student name *
Planned date of H.S. Graduation *
Student Date of Birth *
Student Signature *
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Signature: (Type in your full name)
I agree to the terms included.

Parent Permission:

I reviewed and give my consent to the release of information as described above regarding the enrollment, financial aid, academic standing, and graduation status of my son/daughter from his/her postsecondary institution, the National Student Clearinghouse, and/or state data system to Central College ETS.  I understand this information will be maintained and used for the sole purposes described above.     

Parent/Guardian Signature *
Click here to start signing.
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Signature: (Type in your full name)
I agree to the terms included.

Permission to Release School Records

Student Permission:

I consent to the release of my school records including, but not limited to, demographic data/contact information, enrollment/school transfer information, transcripts, grades and report cards, test scores, disciplinary records and other information regarding my school performance to the Central College ETS program.  I understand the information shared under the terms of this agreement shall be kept confidential and used for the following purposes:

1.  Determining admission to the ETS program.

2.  Developing an individual plan and providing academic advising to support my growth, interpersonal development, and preparation for success in accessing and completing postsecondary education.

3.  Providing data to the U.S. Department of Education and to Central College for the sole purpose of assessing the effectiveness of ETS in providing services to students.

I understand my records will be kept in a confidential file and will be used for the reporting purposes above.  This release shall remain in effect for the date indication below until 12 months following the date of my graduation from high school.  I understand that if I am not admitted to the program, this release shall be immediately null and void.  I understand I may revoke this release at any time by submitting to Central College ETS a date, signed statement denying the release of secondary school records. 

Student Name *
Student Signature *
Click here to start signing.
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Signature: (Type in your full name)
I agree to the terms included.

Parent Permission:

The school my student attends has my permission to release his/her school records to the Central College ETS program to be maintained and utilized as described above.

Parent/Guardian Signature *
Click here to start signing.
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Signature: (Type in your full name)
I agree to the terms included.
This document was developed under a grant from the US Department of Education (USDE).  However, the contents do not necessarily represent USDE policy and you should not assume endorsement by the Federal Government.  ETS is 100% funded through a grant in the amount of $468,456 for the USDE.

 

 

Once you have submitted your application please contact Tate Offenburger at either 641-203-3416 or offenburgert@central.edu and let him know you submitted the application and be sure to tell him your name and school! Thank you!