Thank you for your interest in Alcorn State University Talent Search 61 South Program! Please complete this application as thoroughly as possible. You cannot save and restart this application. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application. If you have any questions, please call our office at (601) 877-3031.

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SECTION 1: STUDENT INFORMATION

Current School *

Last Name *

First Name *

Middle Name

Date of Birth *

Ethnicity *

Address *

City *

State *

Zip *

Phone *

Cell Phone *

Email *

Grade *

We use email and text to send out important ETS Information. May we TEXT the cell number you provided? *

We use email and text to send out important ETS Information. May we EMAIL the email address you provided? *

Do you have access to a home computer with internet? *

What is your cumulative Grade Point Average (GPA)

Indicate by number your most recent letter grades. (EX. 5 A's and 2 B's) *

Do you have the ability and desire to continue education beyond high school (college/vocational/trade school)?

Students can only participate in one TRIO Program at a given time (Educational Talent Search, Upward Bound (UB), or UB Math Science). Are you a part of any other TRIO Program?

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SECTION 2: PARENT INFORMATION

Lives With *

Parent/Guardian #1 full name? *

What is your relationship the student?

Parent/Guardian Cell Number *

We use email and text to send out important ETS Information. May we TEXT the cell number you provided? *

Parent/Guardian #1 Email Address *

We use email and text to send out important ETS Information. May we EMAIL the email address you provided? *

Parent/Guardian #1 Occupation *

Did parent/guardian #1 graduate with a 4-year, Bachelor college degree? *

Parent/Guardian #2: Full Name *

What is your relationship to the student? *

Parent/Guardian #2 Cell Number *

We use email and text to send out important ETS Information. May we TEXT the cell number you provided? *

Parent/Guardian #2 Email Address *

We use email and text to send out important ETS Information. May we EMAIL the email address you provided? *

Parent/Guardian #2 Occupation *

Did parent/guardian #2 graduate with a 4-year, Bachelor college degree? *

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SECTION 3: HOUSEHOLD INFORMATION

How many people live in your household including students away at college. *

Household Income Range *

Please indicate below if you receive any other sources of income. *

Names of Other School Age Siblings in Home *

SIGN and SUBMIT

I give my permission for my child to participate in the Educational Talent Search (ETS) Program through Alcorn State University. I verify all of the information on this application is true and to the best of my knowledge, correct. *

Signature Type: SMS Start Over

After validation, the cell phone number will become part of the electronic signature.

Cell Phone Number:

Enter characters above to send message.

Today's Date: *

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SECTION 4: EDUCATIONAL RECORD RELEASE

The Family Educational Rights and Privacy Act of 1974 (FERPA), as amended, is a federal law that protects the privacy of student education records. The Educational Records Release is required for participation in the Educational Talent Search Program. By completing this authorization, I give permission for the Educational Talent Search (ETS) Program at Alcorn State University to have access to all middle school/high school, student educational related records of:

Student's First Name *

Student's Last Name *

Student's Date of Birth *

I understand, the student’s Educational Records Release must be signed in order for the student to receive services from the Educational Talent Search Program (ETS).

Student educational record information may be used to:

determine eligibility to receive services from the ETS Program,
monitor status and progress in secondary school
guide student regarding academic advising,
communicate with school personnel regarding the needs of the student.
Track post-secondary education attendance and completion.

I give the Educational Talent Search Program, permission to have access to my child’s middle school/high school information in the school data system. Necessary records may include, but are not limited to information in the secondary educational records such as grade reports/transcripts, test scores, attendance, behavior reports, medical, court documentation and other records. It is my understanding that these records will be released only to those who have legitimate educational interest, or otherwise are required by law to be disclosed by ASU.

I understand the Educational Records Release can be revoked at any time by submitting a written request to the Educational Talent Search Program at Alcorn State University.

Parent/Guardian Signature (Student may sign if 18 years of age)

Signature *

Please select a signature verification type.

Date Signed *