Academic Talent Search Program Application

Section I

First Name

Middle Name

Last Name

Phone Number

Email Address

Mailing Address

Country

Street

City

Region

Postal Code

Birthdate

Age

Are you a U.S. citizen?

If No, are you a permanent resident?

What is your citizenship ?

School

Grade

If selected "Other" for Grade please elaborate here:

Section II

Are you Hispanic?

Please select any that apply:

Gender:

12th Graders Only-Please list below your top three colleges you will be interested in attending:

College 1:

College 2:

College 3:

12th Graders Only-Please list below your top career interest:

Interest 1:

Interest 2:

Interest 3:

Section III

Section IV

Emergency Contacts

First

Last

Phone

Relationship

First

Last

Phone

Relationship

Section V

Number in Household:

Mother's Name

Has completed 4-year college?

Father's Name

Has completed 4-year college?

Name of parent(s)/guardian whom the applicant lives with:

I (We) the Parent(s) /Guardian of aforementioned student above grant my son/daughter permission to participate in the Academic Talent Search Program. I authorize the Academic Talent Search Program of Canisius College to access my son/daughter’s report cards, transcripts, test scores, and other relevant information for my child to participate in the program. If applicable, I allow Academic Talent Search to have access to my child’s free or reduced lunch application information. I also allow Academic Talent Search to photograph my son/daughter during activities for use in newsletters, brochures, and/or press releases, and finally, to verify my son's/daughter's postsecondary enrollment at any institution. *Canisius Academic Talent Search Program does not share personal information. By typing name below and submitting you are agreeing with above mentioned statement.

Parent(s) or Guardian Signature

Today's Date

Student Signature

Today's Date