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Talent Search
645 Patriot Avenue, Martinsville, VA 24112
Phone: 276-656-5493 Fax: 276-656-0352
Email: talentsearch@patrickhenry.edu

Section A: Applicant Information

*Name
*Mailing Address
*City *State *zip
*Primary Phone #
Secondary Phone #
*Birthdate
*Male
*Female
Student Email
Ethnicity
    *American Indian   Hispanic   Asian   African American    White   Multi-Racial   Other
*US Citizen Yes   No (if no, please complete residency status) Permanent Resident
*Current Grade Level
*Middle/High School
Are you in any of the following programs: AVID    Upward Bound   Upward Bound Math and Science

Section B: Family Information

Program Eligibility Documentation

Parent Education:

*Please indicate whether biological or adoptive mother has a 4-year college degree: Yes    No
*Please indicate whether biological or adoptive father has a 4-year college degree: Yes    No
*Free or Reduced Lunch: Yes    No    Did not apply

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.

TAXABLE INCOME
$0 - $18,090
$18,091 - $24,360
$24,361 - $30,630
$30,631 -$36,900
$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:

Child Support Received
Welfare Benefits
TANF
Untaxed Social Security Benefits
Veteran's Benefits
Any other untaxed income and benefits, such as Black Lung
Worker's Compensation
Unemployment Benefits


Emergency Contact/Medical Information

*Emergency Contact 1
Email
Relation
Home Phone
Work Phone
Cell Phone



*Emergency Contact 2
Email
Relation
Home Phone
Work Phone
Cell Phone



*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

Parent Agreement:

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.

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Student Agreement:

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.

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