We ask the following questions because this program is federally funded / future funding depends on the population we serve. Contact Information Name * First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Address Country - None -United States Address 1 Address 2 City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code Phone * E-mail * Parent E-mail Demographics Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Are you a U.S. Citizen? * Yes No Alien Registration No. A# Other Resident Status The next two questions about gender and race/ethnicity are optional, but answering them is helpful for ETS reporting purposes. Gender Identity Female Male Race / Ethnicity American Indian / Alaska Native, non-Hispanic/Latino Asian, non-Hispanic/Latino Black or African, non-Hispanic/Latino Hispanic/Latino of any race White, non-Hispanic/Latino Native Hawaiian or Other Pacific Islander, non-Hispanic/Latino Two or more races, non-Hispanic/Latino Race or Ethnicity Unknown School * - Select -Burncoat Senior High SchoolClaremont AcademyDoherty Memorial High SchoolKeith Middle SchoolNew Bedford High SchoolSouth High Community SchoolSouthbridge High SchoolSullivan Middle School Current Grade * - Select -6th7th8th9th10th11th12th Family Information Number of Family Members Who Live With You (include yourself) * Family Member 1 Name First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Age Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Relationship Other... Name of school or occupation Year in School Family Member 2 Name First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Age Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Relationship Other... Name of school or occupation Year in School Family Member 3 Name First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Age Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Relationship Other... Name of school or occupation Year in School Family Member 4 Name First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Age Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Relationship Other... Name of school or occupation Year in School Family Member 5 Name First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Age Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Relationship Other... Name of school or occupation Year in School Family Member 6 Name First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Age Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Relationship Other... Name of school or occupation Year in School Did the parent (s) with whom you live graduate from a four-year college? * Yes No Name of Parent 1 College Name of Parent 2 College Financial Information Primary Income / Support Sources * Pertaining to parents/guardian (or student if independent) Salary TAFDC (welfare) Social Security Benefits Retirement Disability Benefits Veteran’s Benefits Pension S.S.I. Unemployment Benefits EA-EDC Child Support Other Income Level * Select the range of your family’s taxable income for the previous year. For more than 8 in family, add $7,080 for each member. $0 - 21,870 $21,871 – 29,580 $29,581 – 37,290 $37,291 – 45,000 $45,001 – 52,710 $52,711 – 60,420 $60,421 – 68,130 $68,131 – 75,840 Over $75,841 Parent / Guardian / Release of Information I certify that the information is correct and understand that by signing this form, I give permission to the Educational Talent Search Program to access my child’s educational enrollment in order to track their educational progress. I authorize MassEdCO to contact me regarding the Educational Talent Search Program. I also consent to periodic e-mails and texts to be sent to my child through e-mail addresses and cell # provided to MassEdCO. By choosing to enroll in Educational Talent Search, my child and I certify that he/she is not and will not enroll in either GEARUP or Upward Bound without notice to Educational Talent Search. Parent or Guardian’s Signature Student Signature
