Are you in any of the following programs:
Upward Bound Math and Science
Section B: Family Information
Program Eligibility Documentation
Section C: Family Size--this only includes immediate dependents
(In the case of divorce, please list the parent with whom the child resides the majority of the time)
How many people live in your household? (exemptions claimed on line 6d of the federal tax return)
Section D: Parent Taxable Income
Use your 2016 1040, 1040-EZ or 1040A Tax Form in completing this section.
If you did not file a tax return, please complete the untaxable income section of this form.
Check the income range that is reflected on your TAXABLE INCOME on your Federal Tax return.
This information is found on 2016 IRS Form 1040 Line 43 or on 2016 IRS Form 1040A Line 27.
Effective January 25, 2016 until further notice.
$0 - $18,090
$18,091 - $24,360
$24,361 - $30,630
$36,901 - $43,170
$43,171 - $49,440
$49,441 - $55,710
$55,711 - $61,980
$61,981 or more
If you did not file a tax return or if you receive untaxed benefits, indicate the source of non-taxable income:
Emergency Contact/Medical Information
*Please indicated medical conditions/allergies of student (special needs, physical limitations, food allergies):
*List any medications your child is currently taking?
*Does your child experience motion sickness? Yes No
*Is your child a proficient swimmer? Yes No
*Staff may perform basic first aid on my child (e.g. band-aids, cold pack) Yes No
*Please call me for authorization if my child is requesting over-the-counter medications (e.g. pain relievers or motion sickness tablets) Yes No
*My child has permission to participate in fieldtrips, activities and events sponsored by Talent Search and partner organizations (MHC After 3, AVID, etc) Yes No
*I certify all information on this document is accurate.Yes No
I understand that the information I have provided here is for the use of PHCC Talent Search and partner agencies only and will remain confidential. I relieve the program of any responsibility for any accidents, illnesses, or injuries, which may result from participation and allow them to take pictures for program documentation and promotion.
Be it known that I, as parent/guardian of the named student, hereby grant unto any medical doctor or hospital my consent and authorization to provide such aid, treatment, or care to said student as, in judgment of the doctor or hospital, may be required on an emergency basis in the event said student should be injured or stricken ill while participating in a Talent Search sponsored event or field trip.
I certify that my child is participating in the Patrick Henry Community College Talent Search Program.
I understand that Talent Search staff is required by federal regulations to track participant grades,
SOL scores, academic progress throughout high school (including a final transcript) and access to
college enrollment and academic standing (for six years post-secondary graduation).
I give permission for school records to be released and for PHCC Talent Search staff to communicate with teachers,
guidance counselors’, or other school staff for that duration.
You MUST click Keep this signature
I would like to be a participant in the Talent Search Program. If I am accepted into the program,
I agree to abide by ALL of the rules and regulations of the program, and participate in all activities.
I will be respectful to staff and peers participating in the program on and offsite.
I understand that violation of any of these may result in my suspension from the program.
You MUST click Keep this signature