ETS Application Checklist

Complete ETS application *Black Ink Only*

Copy of parents’ most recent income taxes- SIGNED & DATED

Copy of students’ Social Security card- SIGNED & DATED

Please, make sure all documents are completed before turning in your application. If you have any questions you may call our ETS office at 760-744-1150 ext. 8130.

Thank you!

Aplicación ETS- Lista de verificación

Aplicación completa *tinta negra*

Copia de sus impuestos mas recientes - firma y fecha

Copia de la tarjeta de Seguro Social de su estudiante - firma yfecha

Por favor, asegúrese que todos los documentos necesarios estén completos antes de entregar su aplicación. Si tiene alguna pregunta llámenos a nuestra oficina al número 760-744-1150 ext. 8130.

Gracias!

Information to Include:

Copy of parent/s or guardian/s income tax forms.

Specifically, the pages that include the following

information.

Number of dependents

Taxable income

We do not accept W2 forms. If parents do not file

taxes, please ask for a Written Declaration Form to state

the family’s number of dependents and annual income.

Examples of Income Tax Forms:

1040 Income Tax Form

1040A Income Tax Form

The first two pages usually provide the number of

dependents (square on line 6) and taxable income (line

43 on 1040 and line 27 on 1040A).

Please provide a copy of these two pages, both signed

and dated by parents/guardians. If you have any

questions please do not hesitate to call our office at

760-744-1150 Ext. 8130.

Thank you.

Palomar College ETS Staff

Example of Income Tax Form for PC ETS Application

Información Necesaria:

Copia de formulario de impuestos de padres/tutores. Es-

pecíficamente, las paginas que incluyan la siguiente in-

formación.

Numero de dependientes

Impuestos sobre ingreso

No aceptamos formularios de W2. Si padres o tutores no

presentan declaración de impuestos, favor de pedir un

Formulario de Declaración Escrita para indicar el numero

de dependientes y ingreso anual de la familia.

Ejemplos de formularios de impuestos:

1040 formulario de impuestos

1040A formulario de impuestos

Usualmente, las primeras dos paginas proveen el numero

de dependientes (cuadro en línea 6) y impuesto sobre in-

greso (línea 43 en 1040 y línea 27 en 1040A).

Favor de proveer copias de estas dos paginas, con

firma y fecha por los padres/guardian. Si tiene

alguna pregunta por favor llámenos al siguiente numero,

(760) 744-1150 Ext. 8130.

Gracias.

Personal de Palomar College ETS

Ejemplo de Formulario de Impuestos Para Solicitud PC ETS

PALOMAR COLLEGE®

Palomar College

Educational Talent Search Application

Step 1: Student Information

Please answer the following questions: 1. Name:

2. School Attending: C DDA C HVMS C MMS

3. Current Grade Level:

4. Mailing Address:

treet

tty

c 3th c 9th c 1 Qth c 11

th

tote ,p

Apt.#

C EHS C OGHS

Graduating H.S. in: 20 __

5. Home Phone#: ( __ ) ______ _ Cell Phone#:(_) ______ _

7. Date of Birth---

9. Is the student Hispanic or Latino? C Yes

8. Gender: C Female

CNo

10. What race do you identify with? (Please check all that apply)C Native African or African American

C Male

CAsian American or Asian C American Indian or Alaskan Native

C Native Hawaiian/Pacific Islander C Caucasian (white) COther: ___________ _

11. What is the primary language spoken at home? ____________ _

12. With whom do you live? C Both Parents C Mother only C Father only C Other: ______ _

13. Check all programs you are presently a participant of or are currently applying to.

C AVID C Upward Bound CSUSM C ETS WAHUPA C Upward Bound

Citizenship

ETS is funded by the U.S. Department of Education. Regulations require that to participate, an individual must be a U.S. citizen/national or a permanent resident of the U.S.

Are you a U.S. citizen or national? C Yes C No

Social Security Number: __ _

If no, are you a permanent resident of the U.S.? C Yes C No

Alien Registration Card#: __________ *required*

Admission to the Palomar Community ETS Program is open to those who meet the eligibility

criteria, regardless of gender, race, national origin, age, religion, or disability. For more Information, call (760) 744-

1 ISOext. 8130or8131

The Palomar College Educational Talent Search Program (PC ETS) is 100%Ffederally funded by the U.S. Department of Education.

C RMMS C VIDA C RBVHS C VHS

C DDA C MMS

c 3th c 9th c 1 Qth c 11

th

C EHS C OGHS

Graduating H.S. in: 20 __

C RMMS C VIDA C RBVHS C VHS

C HVMS

Palomar College

Educational Talent Search Application PALOMAR COLLEGE®

Ste 2: Parents/Guardian Information

MOTHER/GUARDIAN INFORMATION

1. Name of Mother/Guardian:�--------------------

2. Home Phone: (_) ____ _ 3. Cell Phone:(_) ____ _

4. Work Phone: (_) ____ _

5. Mailing Address:

ree p.

,ty State Ip

6. Email: ____________ 7. Occupation: __________ _

Is the Mother/Guardian currently: C Employed

C Disabled

C Unemployed

C Deceased

FATHER/GUARDIAN INFORMATION

1. Name of Father/Guardian:

C Retired

�--------------------

2. Home Phone: (_) ____ _ 3. Cell Phone:(_) ____ _

4. Work Phone: (_) ____ _

5. Mailing Address:

ree p.

ity State Zip

6. Email: ____________ 7. Occupation: __________ _

Is the Father/Guardian currently: C Employed

C Disabled

C Unemployed

C Deceased

PARENT EDUCATION INFORMATION

C Retired

To be eligible as a first generation student, neither of your parents/guardians can possess a bachelor's

degree (also known as a "four- year degree").

Mother/Guardian

Father/Guardian

Please circle the highest grade level completed by each parent/guardian

Elementary High School Diploma College Degree

1 2 3 4 5 6 7 8 9 10 11 12 CYes

1 2

CNo

1 2 3 4 5 6 7 8 9 10 11 12 CYes

1 2 CNo

Admission to the Palomar Community ETS Program is open to those who meet the eligibility

criteria, regardless of gender, race, national origin, age, religion, or disability. For more

information, call (760) 744-1150ext. 8130or8131

3 4 C Yes CNo

3 4 C Yes

CNo

The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.

2

lnformaci6n de la madre o guardian 1. Nombre de la Madre o Guardian:

---------------------

2. Telefono de Casa:(_) _____ 3. Telefono Celular: (_) ____ _

4. Telefono de Trabajo: (_) _____

5. Direcci6n:

a e p.

c,udad Estado Cod,go Postal

6.Correo Electr6nico: ____________ 7. Ocupaci6n: __________ _

La Madre o Guardian actualmente esta: C Empleada

C Deshabilitada

C Desempleada

C fallecida

lnformaci6n del Padre o guardian 1. Nombre de la Padre o Guardian:

C Retirada

---------------------

2. Telefono de Casa:(_) _____ 3. Telefono Celular: (_) ____ _

4. Telefono de Trabajo:(_) ____ _

5. Direcci6n:

a e p.

Cwdad Estado Cod1go Postal

6.Correo Electr6nico: ____________ 7. Ocupaci6n: __________ _

La Padre o Guardian actualmente esta: C Empleada

C Deshabilitada

C Desempleada

C fallecida

C Retirada

lnformaci6n de la educaci6n de los padres

Para ser elegible como un estudiante de primera generaci6n, ninguno de tus padres deben poseer un

bachillerato (tambien conocido como un "tftulo de 4 arios").

Madre

Padre

Favor circule el nivel mas alto de educaci6n recibida par cada padre/guardian.

Elementarfa Preparatoria Diploma Colegio Titulo

1 2 3 4 5 6 7 8 9 10 11 12 csr

1 2

CNo

1 2 3 4 5 6 7 8 9 10 11 12 csr

1 2 CNo

Admission to the Palomar Community ETS Program is open to those who meet the eligibility

criteria, regardless of gender, race, national origin, age, religion, or disability. For more

information, call (760) 744-1150ext. 8130or8131

3 4

3 4

lJ Sf CNo

Csr CNo

The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.

lnformaci6n de los padres o guardian

Coordinator Name (print) Coordinator Signature Date

Colegio Palomar

Solicitud de Educational Talent Search PALOMAR COLLEGE®

Paso 3: Divul aci6n de lnformaci6n

Divulgacion de informacion del estudiante

lnformaci6n provefda a ETS es confidencial y no sera divulgada sin la autorizaci6n del estudiante. Al firmar, autoriza a ETS a recibir y dar

informaci6n a todas las instituciones educativas para que ayuden en la planeaci6n educativa, verificar inscripciones, y asegurar oportunidades

de ayuda financiera para los participantes del programa. Ademas, la informaci6n puede ser divulgada al departamento de educaci6n para

demonstrar la efectividad del programa al solicitar nuevos fondos.

La informaci6n requerida va a ser utilizada para ayudarnos en proveer servicio para ti. Para poder proveer en servicio mas adecuado y

efectivo, necesitamos obtener informaci6n de diferentes fuentes como la preparatoria, colegios, agencias de examenes, consejeros, oficiales

de admisi6n y ayuda financiera, trabajadores sociales, etc. Toda la informacion recibida se mantendra confidencial con el acatamiento de

los derechos de familia y la ley de privacidad.

• Requerimos una copia de transcripciones de la secundaria o preparatoria y/o del colegio, resultados de examenes y/o documentaci6n de grados.

• Requerimos una copia del resultado de los examenes (STAR/CST, ACT, SAT) de American college testing, College Board, y Educational Testing Service.

• Comunicarse con representativos de agencias o instituciones post-secundarias en mi nombre.

Ademas, yo verifico que la informaci6n provefda en esta solicitud es verdadera y correcta

Student Name (Print) Student ID Number Student School Name Date

Parent Name (Print) Parent Signature Date

Uso de fotografias e imagenes:

3

Gran parte de nuestra publicaci6n y exito de la comercializaci6n es a partir de la utilizaci6n de fotos y videos tomados de los estudiantes de ETS

durante los eventos del programa. Al firmar a continuaci6n, nos da el derecho irrevocable a usar su nombre, foto o video en todas las formas y medios

de comunicaci6n y de todas las maneras, incluidas las representaciones arregladas o alteradas, con fines publicitarios, comerciales o cualquier otro

prop6sito legal, y usted renuncia a cualquier derecho a inspeccionar o aprobar la version final (s), incluyendo copias impresas que se pueden crear en

relaci6n con ellos. He lefdo esta nota y estoy plenamente familiarizado con el contenido.

Firma del Padre Fecha

FOR OFFICE USE ONLY

Total Taxable family income (line 43 on the 1040 form, line 27 on the 1040A form and line 6 for the 1040EZ form)

reported on Federal Income Tax Return during the most recent tax year is: $ ____________ _

Total number of people supported by this income is: _________ _

The 20 __ federal TRIO programs annual low-income

Level for a family unit with _____ members is: I SI I I I

Eligibility: C LI & FG C LI ONLY C FGONLY C DI ONLY C LI & DI

Date of application entry in Blumen ______ Initials of data entry staff ___ Current overall GPA on transcript ____ _

C Approved/accepted C Not recommended/Denied Reason: ----------------

Supervisor Signature

Admission to the Palomar Community ETS Program is open to those who meet the eligibility

criteria, regardless of gender, race, national origin, age, religion, or disability. For more

information, call (760) 744-1150 ext. 8130 or 8131

Date

The Palomar College Educational Talent Search Program (PC ETSJ is 100% Federally funded by the U.S. Department of Education.

Coordinator Name (print) Coordinator Signature Date

Palomar College

Educational Talent Search Application PALOMAR COLLEGE®

Step 4: Teacher/Counselor Recommendation Form

________________ is applying for admission to the Palomar College Educational

Talent Search (ETS) program. ETS serves students from 8th to 12th in participating target schools. We are

interested in applicants who wish to pursue a post-secondary education. We greatly appreciate your input

on this student's academic performance and dedication.

Teacher/Counselor name:

ff St ast

School: C DDA C HVMS C MMS C EHS C OGHS

Please answer the following question about this student.

Has this student demonstrated interest obtaining a postsecondary education? C Yes C No

Please check the areas in which you feel that the ETS program could help the student: C Postsecondary planning and selection C Financial aid assistance

C College entrance exams CCareer awareness

C Academic skills

Please rate the student in the following area (5 being excellent and 1 being below average)

1. Leadership: s 4 3 2 1

2. Dependability: s 4 3 2

3.Confidence: s 4 3 2

4. Work Ethic: s 4 3 2

5. Attitude: 5 4 3 2

Counselor/teacher Signature Date

Admission to the Palomar Community ETS Program is open to those who meet the eligibility

criteria, regardless of gender, race, national origin, age, religion, or disability. For more

information, call (760) 744-1150ext. 8130or8131

The Palomar College Educational Talent Search Program (PC ETS) is 100% Federally funded by the U.S. Department of Education.

4

C RMMS C VIDA C RBVHS C VHS