Tsapp 2014

Rutgers University Newark Academic Foundations Center 110 Warren Street Bradley Hall, Room 120 Newark, NJ 07102
Main Office: (973) 353 3563 Fax Number: (973) 353 1945 Website: www.ncas.rutgers.edu/afc/ts
Please PRINT All Information in Blue or Black Ink Only
STUDENT & PARENT INFORMATION:

Last Name
First Name
Date of Birth:
/
MM
/
DD
Social Security #:
Middle Name
Gender: Female
Age:
Male
YYYY
(SS# Required)
Are you a US Citizen? Yes
No
(If not a US Citizen, are you a Permanent Resident? No Yes, please indicate Green Card #:
Ethnicity:
African American
Pacific Islander
Alaska Native
White
American Indian
Other:
Asian
)
Hispanic/Latino
Student Email Address:

Home Address:
Do you live with:
Street
Apt.
City
State
Zip Code
Both Parents Mother Only Father Only Legal Guardian:

Relationship to Student (i.e. Grandparent, etc.)
Parent/Guardian Name(s):
Parent/Guardian Marital Status:
Home Phone #: (
Single
Married
Cell Phone #: (
Separated Divorced
Alternate Phone #: (
Widowed
)
Parent Email Address:

SCHOOL INFORMATION:
Current School Year:
Grade Level: 6th
7th
8th
9th
10th 11th 12th
Name of School:
Guidance Counselors Name:
Year of Expected High School Graduation:
If not a student in grade 6-12, please note here your current status (for example, Veteran, etc.):
PROGRAM ELIGIBILITY STATUS & NEEDS ASSESSMENT*:
(Parent(s)/Guardian(s), please provide the following information)
Level of education of Mother/Guardian:

Level of education of Father/Guardian:
Number of people in household:
Does mother have a 4-year degree?

Does father have a 4-year degree?
Adults=
Children=
No
No
Yes
Yes
Household Taxable Income: $
*According to TRiO Legislation 1070a-11 Program Authority; authorization of appropriations (e) Documentation of status as a low-income individual (1) Except in the case
of an individuals status pursuant to subsection (h)(4) shall be made by providing the Secretary with (A) a signed statement from the individuals parent or legal guardian; (B) verification from
another governmental source; (C) a signed financial aid application; or (D) a signed United States or Puerto Rico income tax return. Please be advised by filling out this section and signing the
program application on page 2, this document will serve as your statement, as in (A).
Student is in need of the following services from Talent Search: (Please select all that apply)
College Entry Information
Improving Grades Overall
Assistance with Educational/Career Goals
Tutoring Services/Resources
Financial Literacy Information
Test Taking Skills (i.e. NJ ASK, HSPA, SAT/ACT)
Financial Aid Information
Other:
Page 1 of 2 (Turn Over & Sign the Application)
Student Name:
Please complete the following sections and provide a signature to complete this application.
MEDICAL RELEASE & EMERGENCY INFORMATION:

History of health conditions (Please include any food allergies, etc.):
Physician Name:
(if applicable)
Phone #: (
In Case of an Emergency, Contact:

Name
Emergency Contact Phone #(s): Home #: (
Relationship to Student
and/or Cell Phone #: (
Every reasonable precaution will be taken to provide safety and care of your child. Every effort will be made to notify you and/or
your Emergency Contact (listed) in the event of an accident or injury, which may require emergency care. If you cannot be contacted,
permission is needed to seek medical attention. All financial responsibility for hospitalization and medical care provided, in the case
of an emergency, is to be assumed by the parent/guardian.
Can the program seek medical attention if needed? No Yes, Parent/Guardian please sign here:
AUTHORIZATION FOR RELEASE OF ACADEMIC RECORDS:

(For duration of Program Participation)
I hereby voluntarily authorize the school to release information to the Talent Search Program. Specifically, I authorize disclosure of
the following information or category of information class schedules, standardized test scores (NJ ASK, HSPA, and NJ Biology
Competency Exam), quarterly report cards, transcripts, disciplinary actions, evaluations, attendance history and medical records for
the purposes of evaluating eligibility for admission and participation. This authorization will remain in effect from the date it is
executed until revoked by me, in writing, and delivered to the Talent Search Program.
Parent/Guardian Signature:
Date:
PHOTO & MEDIA RELEASE:

I hereby freely and irrevocably grant Rutgers University and its authorized employees and agents, the absolute right and
permission to copy, exhibit, copyright, use, take, distribute and/or publish my photographic likeness, name, voice, and/or image
made in relation to my participation in the Activity in photographs, video and in any and all other media forms.
Date:
APPLICATION CERTIFICATION & AUTHORIZATION:

I certify that this information is true and correct to the best of my knowledge. I understand that this application is being made in
connection with receipt of Federal & State funds and that Organization Officials may verify this information. I approve and authorize
my childs application for the Rutgers University-Newark Talent Search Program. Additionally, I hereby authorize my child to
participate in all activities organized by the Rutgers University-Newark Talent Search Program and give the program permission to
request report card, transcript & test scores for the duration of my childs participation.
Date:
Student Signature:
Date:
Thank you for completing the program application. You will be notified of admission status shortly.
Applications can be returned the following ways:
Fax to: (973) 353-1945
Drop off at the Guidance Department or Main Office at your childs school
Mail or Return to:
Mr. Jason Moore, Director
TRiO Talent Search Program, Rutgers University-Newark
Academic Foundations Center, Bradley Hall, Room 120
110 Warren Street Newark, New Jersey 07102
Page 2 of 2 (Turn Over & Sign the Application)

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Rutgers University Newark Academic Foundations Center 110 Warren Street Bradley Hall, Room 120 Newark, NJ 07102

Please PRINT All Information in Blue or Black Ink Only

STUDENT & PARENT INFORMATION:

Are you a US Citizen? Yes

Student Email Address:

Do you live with:

Both Parents Mother Only Father Only Legal Guardian:

Parent Email Address:

Grade Level: 6th

10th 11th 12th

Year of Expected High School Graduation:

Level of education of Mother/Guardian:

Number of people in household:

Does mother have a 4-year degree?

Household Taxable Income: $

Improving Grades Overall

Assistance with Educational/Career Goals

Financial Literacy Information

Test Taking Skills (i.e. NJ ASK, HSPA, SAT/ACT)

Financial Aid Information

MEDICAL RELEASE & EMERGENCY INFORMATION:

In Case of an Emergency, Contact:

Emergency Contact Phone #(s): Home #: (

and/or Cell Phone #: (

AUTHORIZATION FOR RELEASE OF ACADEMIC RECORDS:

PHOTO & MEDIA RELEASE:

APPLICATION CERTIFICATION & AUTHORIZATION:

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