Today's Date

A. Participant Information
1. Your name: Last Name First Name

2. What is your program start date:

3. What is your program end date:

4. What is your Educational Talent Search Counselor's Name:

5. Are you a: A New Participant A Continuing Participant Prior Participant

6. If you are currently not in school, what is your status (leave blank if not applicable).

Adult without high school credential

High school (or GED) graduate

Post secondary stop out

Post secondary transfer

7. Are you a Veteran: Yes No

8. Do you have limited English proficiency: Yes No

B. Give us your current contact information:
1. Parent #1- Last Name: First Name:

2. Parent #2- Last Name: First Name:

3. Address:

4. City: State: Zip Code:

5. Phone Number: Alternate Phone Number:

6. Email Address:

C. School Information
1. School Name:

2. School Counselor/Contact Name:

3. Click on the circle that applies to you.

Secondary School Promotion: Yes No

Secondary School Graduation: Yes No

Secondary School Re-entry: Yes No

4. Participant Status:

Promoted to next grade in middle school

Promoted from middle school to high school

Promoted to next grade in high school (not graduated)

Retained in current middle school

Retained in current grade in high school

Dropped out of middle school

Dropped out of high school

Re-entered secondary school/re-enrolled in GED or other high school equivalency program

Received high school diploma

Obtained a GED/high school equivalency degree

Other (e.g., death)

Unknown

D. Have you received or completed the following?
1. Assistance in applying for post secondary admissions: Yes No

2. Assistance in applying for student financial aid: Yes No

3. Applied for admission to programs of post secondary education: Yes No

4. Applied for student financial aid for post secondary education: Yes No

E. Status for enrolling into post-secondary education
1. Post secondary Admission: Yes No

2. Post secondary re-entry/transfer: Yes No

3. Post secondary Enrollment:

Enrolled in a program of post secondary education (first-time enrollment in post secondary education)

Re-enrolled in (or re-admitted to) a program of post secondary education (include transfer
participants)

4. If you are not currently enrolled in post secondary education, which of the following applies to you?

High School graduate not enrolled in program of post secondary education

Withdrew from post secondary education

Other

5. What kind of institution/s are you expecting to enroll at?

Public, two-year institution

Private, not-profit, two-year institution

Public, four-year institution

Private, non-profit, four year institution

Public or non-profit vocational/technical institution

Proprietary school (specialty school)

Unknown

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