* All fields are required.

Parent/Guardian: Last First

Student: Last First

Address: Street City Albany Attapulgus Baconton Bainbridge Barney Barwick Boston Brinson Cairo Calvary Camilla Climax Colquitt Coolidge Decatur Dixie Hahira Megis Moody Afb Morven Ochlocknee Pavo Pelham Quincy Quitman Sale City Thomasville Valdosta Whigham  Georgia ZIP County Brooks Decatur Dougherty Grady Lowndes Thomas

Home Phone #:          Work Phone #: 

DOB:             Age:              Sex:  Male    Female

School:  School Bainbridge High School Cairo High School Central Middle School Hutto Middle School J.L. Newbern Middle School Mithcell Baker High School Mitchell County Middle School MacIntyre Park Middle School Thomas County Central High School Thomasville High School Washington Middle School             Grade:  Grade 6 7 8 9 10 11 12

Please give numerical Grade Point Average: 

Are you a U.S. Citizen?  Yes    No           

Race:  Race White (Caucasian) Black (African-American) Hispanic Asian American American Indian Other

Do you have any documented disabilities?   No Yes

If yes, explain:   

Emergency Contact:  Name     Emergency Phone #:  

Guidance Counselor/Specialist's Name: 

*Parents, please be advised that occasionally, television/newspaper crews advertise stories on after-school enrichment programs.  Also, brochures will be developed which may include photographs of children participating in the program.  If you do not want your child's photograph to be included in brochures, television or print news articles, please indicate this below. 

  No, you do not have permission to include my child's photograph in print or television media.

Dear Parent/Guardian:

The Department of Education in Washington D.C. funds the Educational Talent Search Program.  We are required to provide services to students who are potential first generation college students.  Please help us meet these criteria by completing the following questions:

Number of People living in your household:    Household 1 2 3 4 5 6 7 8 9 10 or more

Your household income last year:    Household Income $0 - $13,470 $13,471 - $18,180 $18,181 - $22,890 $22,891 - $27,600 $27,601 - $32,310 $32,311 - $37,020 $37,021 - $41,730 $41,731 - $46,440 More than $46,731 N/A

Are you a single parent or guardian?   Yes No

*THESE QUESTIONS MUST BE ANSWERED*

*Does your child receive free or reduced lunch?   Yes No

*Did you or your spouse GRADUATE from a four-year college?   Yes No

If you answered No above:    Highest educational level you have completed

                                                 Highest educational level completed by your spouse 

By submitting this application, you hereby acknowledge that this information is correct to the best of your knowledge.

After you submit this application, you will be taken to the Academic Plan Form.