The Gloria J. Taylor Foundation Educational Talent Search
Online Application

For Office Use ONLY

Admitted______   

Denied______ Reason:__________________________

Approved by: Educational Talent Search Director_________ Date_________

LI/PFG_____ LI Only_____ PFG Only_____ Other_____

 
Who referred you to the Gloria J. Taylor Foundation?

If you prefer to complete a paper copy, please go to: https://gjtf.org/wp-content/uploads/2021/10/ets-3.pdf

Mail completed applications to:
The Gloria J. Taylor Foundation ETS Program | 20080 Governors Dr. | Olympia Fields, IL 60461
Scanned applications can be sent to info@gjtf.org

Start Online Application Here:

STUDENT INFORMATION
First Name *
Last Name *
Participant's School *
If you selected other, enter the name of your school hear. If your school was listed, type N/A *
Student School ID Number *
Current Grade Level *
Date of Birth *
Current Age *
Address *
City *
State *
Zip *
Cell Phone *
Email *
Ethnicity *
If you selected American Indian, please indicate your tribal affiliation
Please confirm that you ARE NOT currently in any other TRIO program(s): Upward Bpund (UB)/Educational Talent Search (ETS)
Gender *
T-Shirt Size *
Do you have siblings in the Educational Talent Search Program?
If you have siblings in the ETS program, what are their names (separate by a comma)?
Do you have a job? If so, please confirm that if you are accepted, your job WILL NOT conflict with the Summer Enrichment Institute.
I HEREBY AFFIRM I AM A CITIZEN OF THE UNITED STATES AND ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE. *
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I agree to the terms included.
PARENT/GUARDIAN INFORMATION
Please only fill out information for the parent(s)/guardian(s) living with the applicant and providing financial assistance:
Name (Parent/Guardian 1) *
Relationship *
Address *
City *
State *
Zip *
Phone Number *
Email *
Highest Educational Level Attained *
Name (Parent/Guardian 2)
Relationship
Address
City
State
Zipcode
Phone Number
Email
Highest Educational Level Attained
FAMILY INCOME VERIFICATION
Household Size *
Household Income *
Please indicate by typing YES if you qualify for any of these programs
Public Assistance
Free or Reduced Lunch
Medicaid
Please confirm Dependent Status or Independent Status based on the criteria below:
Independent Status *
Independent Students must NOT be claimed on parents' income tax return AND meet one of the following criteria (Check all that apply)
You are younger than 18 years of age and have no parent or guardian
Have children or other legal dependents (other than a spouse) who receive more than half of their support from you
At any time since reaching 13 years of age, you were an orphan, in foster care, or a ward of the court
Prior to reaching 18 years of age, you were an emancipated minor, or you had a court-appointed legal guardian
You are homeless (i.e., you lack a fixed, regular, and adequate nighttime residence) or are at risk of becoming homeless
BY SIGNING THIS FORM, YOU ARE VERIFYING THE FEDERAL TAXABLE INCOME YOU REPORTED IS CORRECT TO THE BEST OF YOUR KNOWLEDGE. YOU UNDERSTAND THAT THIS INFORMATION IS ONLY FOR U.S. DEPARTMENT OF EDUCATION FOR VERIFICATION. *
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Signature: (Type in your full name)
I agree to the terms included.
RELEASE FORMS AND AUTHORIZATIONS
(parent and student must confirm and sign)
*
The Gloria J. Taylor Foundation (GJTF) is authorized to provide transportation for my child to program activities. I hereby release the GJTF- Educational Talent Search Program from any responsibility for any criminal act of malice, vandalism, theft and any other unlawful behavior during his/her trips sponsored by The Gloria J. Taylor Foundation. In return for my son/daughter’s attendance to program activities, I fully and forever RELEASE, WAIVE AND DISCHARGE, AND COVENANT NOT TO SUE, The Gloria J. Taylor Foundation (including, but not limited to, its board of directors, employees, students acting as employee and representatives), from and for any and all demands, claims, actions, suits, damages, losses, liabilities, costs and expenses (including, but not limited to, court costs and attorney’s fees), from any causes whatsoever (including, but not limited to, travel delays, property damage and loss, bodily injuries, sickness, disease and death), directly or in directly arising in connection with my son/daughter’s participation in the GJTF ETS Program. If for any reason my son/daughter engages in an unlawful act and is detained by the local police while traveling with the GJTF ETS program, an attempt will be made to notify me. In the event that I can or cannot be reached, I understand that the program staff will leave my son/daughter in the custody of the local police and I assume full responsibility to make arrangements on his/her behalf. 
Photo Release (First, Last Name)
Photo Release Disclaimer (First, Last Name)
Academic Records Release (First, Last Name) *
Transcripts
Standardized Test Scores
Financial Aid Information
ACT/SAT Scores
Release Authorization Signature
Student Release Signature *
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Signature: (Type in your full name)
I agree to the terms included.
Parent Release Signature *
ETS Request for Services: Indicate any services with which ETS can help you with (check all that apply):
Study Skills
Career Guidance
College Preparation
Goal Setting
Self-Esteem
Tutoring/Tutoring Referral
Test Prep (including ACT/SAT)
College Admission Assistance
Paying for College/Financial Aid Assistance
Academic Planning
Financial Literacy
College Visits
What are your future plans? *
What are your educational plans after high school? *
How are your parents/guardians involved in your education? *
GPA *
Do you have the ability and desire to continue education beyond High School? *
Student Signature *
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Signature: (Type in your full name)
I agree to the terms included.
EMERGENCY MEDICAL AUTHORIZATION/HISTORY FORM
(check all that apply)
Asthma
Convulsions/Epilepsy
Heart Defects
Allergies
Currently taking medication
Physical Restrictions
Currently under doctor's care
Hearing deficiencies
Mental disorders
If you checked any of medical/health conditions, please provide details for each one:
Health Insurance Information:
Carrier
Group #
Policy #
Carrier Address
Insured
Relationship to ETS Participant
ID #
My signature authorizes the Gloria J. Taylor Foundation staff to provide medical services to my child, if necessary. I also authorize follow up medical care; the administration of any treatment deemed necessary by a doctor (or in the event the designated preferred practitioner is not available, by another licensed physician or dentist); and/or the transfer of the child to any hospital reasonably accessible. I will not in any way hold the Gloria J. Taylor Foundation responsible for any treatment deemed necessary for medical services.
Parent Signature (must be signed for child to participate in field trips) *
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.