We ask the following questions because this program is federally funded/future funding depends on the population we serve. Student Information Name First Middle Last Suffix Address Address Address 2 City/Town State/Province ZIP/Postal Code Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone E-mail Parent E-mail Date of Birth Are you a U.S. Citizen? Yes No Alien Registration Number A Other Resident Status Gender Identity This question is optional but answering it is helpful for ETS reporting purposes. Female Male Ethnicity This question is optional but answering it is helpful for ETS reporting purposes. 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 No response School Name - Select -Burncoat Senior High SchoolClaremont AcademyDoherty Memorial High SchoolKeith Middle SchoolNew Bedford High SchoolSouth High Community SchoolSullivan Middle School House Green Blue Gold Tan Current Grade - Select -6789101112 Family Information Size of Your Family (include yourself) Family Member 1 Who Lives With You Full Name First Last Age Relationship Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Enter other… Name of school or occupation of this person Year in School Family Member 2 Who Lives With You Full Name First Last Age Relationship Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Enter other… Name of school or occupation of this person Year in School Family Member 3 Who Lives With You Full Name First Last Age Relationship Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Enter other… Name of school or occupation of this person Year in School Family Member 4 Who Lives With You Full Name First Last Age Relationship Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Enter other… Name of school or occupation of this person Year in School Family Member 5 Who Lives With You Full Name First Last Age Relationship Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Enter other… Name of school or occupation of this person Year in School Family Member 6 Who Lives With You Full Name First Last Age Relationship Relationship - None -Student’s parentStudent’s stepparentStudent’s siblingStudent’s childStudent’s grandparentOther... Enter other… Name of school or occupation of this person Year in School Did the parent(s) with whom you live graduate from a four-year college? Yes No Parent 1 College Name Parent 2 College Name 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 - 22,590 $22,591 - 30,660 $30,661 - 38,730 $38,731 - 46,800 $46,801 - 54,870 $54,871 - 62,940 $62,941 - 71,010 $71,011 - 79,080 Over $79,081 Signatures 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 Talent Search Program. I also consent to periodic e-mails to be sent to my child through e-mail addresses provided to MassEdCO. Student signature Sign above Parent or guardian signature Sign above
