1600 W. IMPERIAL HWY., Los Angeles, CA 90047 ▪ (323)242-5523 ▪ Fax: (323) 242-5524
(Complete in Blue or Black Ink Only) Return complete applications to ETS staff or school counselor
Participant & Liability Waiver
Student’s Name: ______Birth date:______
Parent/Guardian Name:______
pARENTAL CONSENT
As a parent and/or legal guardian of the student listed above, I/we authorize and permit my child to participate in any and all academic year and summer component activities (classes, tutorials, advisement sessions, workshops, field trips, work study internships, meetings, field trips, etc.) sponsored and/or conducted by the Educational Talent Search Program at Los Angeles Southwest College. I/we also give permission for my child to be transported between his/her school, the college campus, and the scheduled events when the ETS program has scheduled events for its participants.
I/we do hereby grant permission to the Educational Talent Search Program at Los Angeles Southwest College and its authorized representatives, to furnish first aid as my son/daughter may require, as well as to seek medical attention through the nearest medical facilities when students are on field trips, on campus, or other authorized activities. This permission is conditional upon the understanding that in the event of serious illness or the need for hospitalization and/or major surgery, ETS will use all reasonable efforts to contact me. Failure in such efforts should not prevent ETS from providing emergency
STUDENT SCHOOL RECORDS RELEASE AUTHORIZATION
I/we authorize Educational Talent Search Program at Los Angeles Southwest College to obtain documents relative to and consistent with my child’s education. Such documents may include: a copy of my child’s school transcript, test scores, ACT/SAT or CAHSEE/GED scores, and school lunch program eligibility.
I/we authorize ETS to obtain documents related to my child’s application to or receipt of student financial aid assistance (federal, state, or other), a copy of my award notification from college financial aid office, and college admissions information. I/we understand the information above will be used to monitor my child’s academic performance, assist in providing academic advisement, determine program eligibility, and help with their college planning. I/we understand school records will only be used by ETS and will not be shared with any other group.
The Family Educational Rights and Privacy Act (FERPA)e 20 U.S.C. 1232g, is the federal law providing for review and disclosure of student educational records. The TRIO Programs at Los Angeles Southwest College will not permit access to or the release of personally identifiable information contained in the student educational records to any party without the written consent of the student, except as authorized by FERPA.
I certify by signing below I am agreeing to all the information below.
Parent/Guardian Signature:* ______Date: ______
STUDENT INFORMATION * Required information______
Last Name First Name Middle Name
Street Address*______Apt#______City*______Zip Code*______
Date of Birth*______* Email ______Facebook:______
Home*(______)______Cell (______)______Alt (_____)______
Gender* Male Female Do you have any learning disabilitues? Yes No Unknown
Ethnicity:*
African- American (Black) Asian Caucasion Hispanic (Latino) Native American Pacific Islander Other
CitizenshipStatus:*US Citizen Permanent Resident If yes, what is your Alien Registration #: ______ Other ______
Educational Background * Required information
School Attending:*
Washington Preparatory Animo-Locke 1 Animo Locke 2
Animo Locke 3 Animo-Locke Tech
Middle School 3 Middle School 4 Gompers
Bret Harte Other ______
Grade:______Grade Point Average: ______ / Do you participate in any of the following programs? Check all that apply:
Educational Talent Search Upward Bound
MESA AVID Other______
*Do you wish to attend college/university after high school?
Yes No Uncertain If yes, where _______
Parent or guardian information * Required information
______
PrintFather/Guardian’s name*
______
Relationship to Student*
(_____)______(______)______
Phone Number * Cell Phone
(_____)______
Work Email Address
Do you have a U.S. four-year college degree?*:
Yes No / ______
Print Mother/Guardian’s Name*
______
Relationship to student*
(______)______(______)______
Phone Number* Cell Phone
(______)______
Work Email Address
Do you have a U.S. four-year college degree?*:
Yes No
Household Information * Required information
*sIZE OF FAMILY?: ______(# LIVING IN household)
What is your taxable family income for last calendar year?:
*Please check the appropriate taxable income box:* / Does anyone in your household receive any of the following?
(please check all that apply).
Unemployment Social Security
Disability Free/Reduced Lunch Program at School
Public Assistance Ward/Dependent of court
Veteran’s Benefits Otro: ______
All information is kept confidential. This data is used to determine if your child is eligible for this federally funded program.
$0-16,335
$16,336-22,065
$22,066-27,795
$27,796-33,525
$33,526-39,255 / $39,256-44,985
$44,986-50,715
$50,716-56,445
$56,446+