John Wood Community College

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Educational Talent Search

1301 S. 48^th Street

Quincy, IL 62305 217-641-4381

www.jwcc.edu/students/ets

Parent/Guardian Information

Student’s Name: _____________________________ Student’s Soc. Sec. Number: _________________(optional)

Address: _______________________________________________________________________(city, state, zip)

Home Phone: ______________________ Cell Phone: ____________________________

School: _______________________________ Grade: _______

Name of parent(s)/guardian(s) that student resides with: ______________________________________________

Relationship: ____ Birth parent(s) ____ Step parent ____ Foster parents ____ Grandparent ____ Other

Address: ___________________________________________________________________________________

Street/ PO Box City State Zip

Ethnic background: (check all that apply) ____ Am. Indian/Alaska Native ____ Asian ____ White

____ Black/African American ____ Hispanic/Latino ____ Native Hawaiian or Other Pacific Islander

Student is an U.S. citizen?____ yes ____ no If no, what is residency status? __________________________

Confidential Financial Information

To comply with U.S. Department of Education regulations, we need information about your household income and educational background. All information is confidential.

Did either of the student's parents graduate from a 4-year college? ___ Yes ___ NO

Total number in household: ____________

______ This student receives free or reduced lunch OR

______ My taxable income (from IRS 1040- Line 39, IRS 1040A- Line 25, or 1040EZ- Line 6) was:

___ $0 – 15,315 ___ $25,756-30,975 ___ $41,416 – 46,635

___ $15,316– 20,535 ___ $30,976– 36,195 ___ $46,636 – 51,855

___ $20,536– 25,755 ___ $36,196– 41,415 ___ $51,856 and up OR

______ Social Security Income Statement (please provide a copy) OR

______ Unemployment Income Statement (please provide a copy) OR

______ Retirement Income Statement (please provide a copy) OR

______ TANF (family) Case Number ______________

I give my permission to the school my child attends to provide ETS with transcripts and other academic information that may assist ETS advisors in providing relevant services.
I certify that all income and tax information provided is accurate and I understand that this information will be held in the strictest confidence.
I give my permission to allow the ETS Program to use my student’s name and/or photo in a positive manner to promote the ETS Program and the services it provides.

_______________ ______________________________ ___________________________________

Date Student signature, only if 18 or older Signature of Parent/ Guardian

(Rev: 8/07)