| 1) Your First Name: |
|
|
| 2) Your M.I.: |
|
|
| 3) Your Last Name: |
|
|
| 4) Street Address: |
|
|
| 5) City: |
Philadelphia
|
|
| 6) State: |
Pennsylvania
|
|
| 7) Zip Code: |
|
|
| 8) Phone Number: |
|
|
| 9) Date of Birth: (mm/dd/yy) |
|
|
| 10) Age: |
|
|
| 11) Grade Level: |
|
|
| 12) Student ID Number: |
|
|
| 13) In which school are you enrolled? |
|
|
| 14) U.S. Citizenship: |
Yes No (If No, please be able to provide appropriate documentation as required.) |
|
| 15) Permanent Resident Alien: |
Yes No
|
|
|
|
| EMERGENCY CONTACT
|
| 16) Contact First Name: |
|
|
| 17) Contact M.I.: |
|
|
| 18) Contact Last Name: |
|
|
| 19) Contact Phone Number: |
|
|
| 20) Relationship: |
|
|
|
|
| 21) Ethnic/Racial Classification (Optional): |
|
|
| 22) Gender: |
Male Female
|
|
| 23) With whom do you live? |
Mother
Father
Both
Guardian
Other
|
|
| 24) Please Check All That Apply: |
|
|
|
|
| ELIGIBILITY CRITERIA
|
| 25) Biological/adoptive mother's last name |
|
|
| 26) M.I.: |
|
|
| 27) First Name: |
|
|
| 28) Does natural or adoptive mother have a bachelor's degree?: |
|
|
| 29) Mother's Highest Educational Level Completed: |
|
|
| 30) Biological/adoptive father's last name |
|
|
| 31) M.I.: |
|
|
| 32) First Name: |
|
|
| 33) Does natural or adoptive father have a bachelor's degree?: |
|
|
| 34) Father's Highest Educational Level Completed: |
|
|
| 35) Number of people in household (including yourself): |
|
|
| 36) Family's Yearly Income: |
|
|
| 37) From whom did you hear about Talent Search? (You may check more than one.): |
|
|
|
|
|
