Student Application Packet - Academic Year 2021-2022 - 800 West University Parkway, MS 150, Orem, UT 84058 - Utah Valley University
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Student Application Packet
Academic Year 2021-2022
800 West University Parkway, MS 150, Orem, UT 84058
Phone: (801) 863-8570
www.uvu.edu/trio/etsDear Students and Parents:
Educational Talent Search is a federally funded program for middle and high school students who have the
academic potential to participate in educational opportunities beyond high school, but who need academic
enrichment and encouragement to prepare for a successful post-secondary program of education. Eligibility to
participate in the Utah Valley University Educational Talent Search program is based on the following
requirements:
• Students come from disadvantaged families and/or families where neither parent has a baccalaureate
degree;
• Are enrolled at: Provo High School, Dixon Middle School, Timpview High School, Centennial Middle
School, Mountain View High School, Orem Junior High School, Wasatch High School, Rocky
Mountain Middle School, Timpanogos Middle School, Union High School, Roosevelt Junior High
School or Uintah River High School;
• Are 7th - 12th grade students;
• Are citizens or permanent residents of the United States; and
• Are willing to make a personal commitment to improving their academic skills and striving toward
educational success and achievement.
All Educational Talent Search services are free to the participating student. During the school year activities
include advising, school attitude measure, aptitude testing, tutoring, career planning, educational planning,
college visits, financial aid planning and application, post-secondary planning and application.
Young people who are selected for Educational Talent Search should expect to make a commitment to their
own academic success. They must maintain appropriate grades, participate in activities designed to improve
their chances for current and future success, and plan for their futures. In exchange for their commitments,
Educational Talent Search will provide a lot of help and encouragement toward meeting their goals.
If you are interested in improving your chances for post-secondary admission and success, and you believe that
you may be eligible for the program, fill out the enclosed paperwork and provide the other information that is
requested. If you have any questions, please call the Educational Talent Search Office at (801) 863-8570.
Sincerely,
Dr. Michael M. Campbell Paul Belvin
TRIO Programs Director TRIO ETS CoordinatorEducational Talent Search Student Application
Date ______________ Grade in School: 7 8 9 10 11 12
Expected Graduation Date: 2027 2026 2025 2024 2023 2022
School_________________________________ City________________ District__________________
Student Information
1. Name: ___________________________________________________ SSN: ______ - ____ - _______
2. Address:______________________________________________________________________
City:____________________________ State:___________ Zip Code:_______________
3. Telephone Number: (______)_______-__________ Cell Number: (______)_______-__________
4. Student Email address: _____________________________________ @ ___________________
5. Birth date: _______________________ Age: ______ GPA: _________
6. Place of Birth: ________________________ Sex: OMale OFemale
7. U.S. Citizenship: OYes ONo Permanent Resident: OYes ONo
8. Ethnic group (circle all that apply): Black/African American Native American or Alaskan
Hispanic/Latino Asian Caucasian/White Native Hawaiian or Pacific Islander
9. Are you a past participant in the Talent Search Program? OYes ONo
If yes, when? _______________________ and where? ___________________________
10. With whom are you living? OBoth parents OMother OFather OGuardian
11. Do you have any concerns about your student you want us to know about? __________________
______________________________________________________________________________
12. Facebook Account Name: ________________________________________________________
13. Are you physically challenged? OVisual OMobility OHearing OLearning Disability OOther
14. Are you participating in any other educational federal program (i.e. Gear Up) OYes ONo
Family Information
1. Name of Father: Cell: Email:
2. Name of Mother: Cell: Email:
3. Name of guardian if different from 1 & 2:
4. Telephone number Language spoken at home: Primary Secondary
5. Address of Parent/guardian if different from student
6. Occupation of father: Occupation of mother:
7. Marital status of parents (please check one):
i. OSingle OMarried OSeparated OWidow ODivorced
8. Father’s level of education: i. OGraduated from 4-year college: ONo OYes
ii. ODegree Institution
9. Mother’s level of education: i. OGraduated from 4-year college: ONo OYes
ii. ODegree Institution
10. Number of children in the family Are you the O1st child O2nd O3rd O4th O5th or O of the familyConfidential Family Financial Statement
1. Number or family members claimed as exemptions on taxes.__________
2. Your family’s yearly TAXABLE (not gross) INCOME: _______________
(2020 Form 1040 – Line 15)
3. Is the student authorized for free/reduced school lunch program? OYes ONo
You must include a signed copy of the first 2 pages of your last federal tax form filed
or a signed CONFIDENTIAL FAMILY FINANCIAL STATEMENT Form.
(Income Verification is required before the application will be processed)
Release of Student Information
1. I certify that the answers given in this application are accurate and complete. I agree to provide any verification
information requested by Educational Talent Search. I authorize the staff of Educational
Talent Search to obtain copies of my public school and/or college transcripts, school and career related
assessment scores, GED, ACT, or SAT scores, enrollment verification, free/reduced lunch verification,
and any other documentation necessary for counseling or follow-up on my admittance to an educational
institution, and information related to financial aid applications and awards. I also give permission for
ETS to publish my image in any promotional material without compensation.
2. Student’s signature _____________________________________________ Date __________________
3. Parent/guardian’s signature ______________________________________ Date __________________
Utah Valley University does not discriminate based on race, color, religion, national origin, sex, sexual orientation,
gender identity, gender expression, age (40 and over), disability, veteran status, pregnancy, childbirth, or pregnancy-
related conditions, citizenship, genetic information, or other basis protected by applicable law in employment,
treatment, admission,access to educational programs and activities, or other University benefits or services. The
following office has been designated to handle inquiries regarding non-discrimination: EOAA/Title IX – 801-863-
5704 – 800 W University Pkwy, Orem, 84058, Suite BA 203.FAMILY INCOME VERIFICATION STATEMENT
As part of the Educational Talent Search Application, it is necessary to include information about your family’s
yearly taxable income. This can be obtained from your most recently submitted tax form. Using your 2020 tax
returns to obtain your family’s taxable income please refer to the following:
• Form 1040, line 15
Again, income verification is required before the application is processed. In order to expedite this matter, we
have created this form for you to sign and verify that you make more or less than the annual low-income levels
for your family size. Family refers to you, your spouse and children that you claim as dependents on your
yearly taxes.
* * * ALL INFORMATION WILL BE KEPT CONFIDENTIAL AND SECURE * * *
I, _______________________________________, VERIFY THAT MY FAMILY OF _________ HAS A
YEARLY TAXABLE INCOME FOR THE YEAR ________ MORE OR LESS THAN THE FOLLOWING
(locate the line that matches the size of your family and then mark whether you made more or less than the
income level listed):
PLEASE CHECK THE “LESS” OR “MORE” BOX ACCORDING TO YOUR TAXABLE
INCOME ONYOUR INCOME TAXES.
48 Contiguous States, D.C., and Outlying
Size of Family Unit
Jurisdictions
Less More
1 $19,320
2 $26,130
3 $32,940
4 $39,750
5 $46,560
6 $53,370
7 $60,180
8 $66,990
**** See below!
**** For family units with more than eight members, add the following amount for each additional family
member: $6,810 for the 48 contiguous states.
**(Income Verification is required before the application will be processed) **
(Please submit the first two pages of last year’s income tax (2020) with this application).
Total dollar amount of taxable income (not gross income) for this year is_________.
_______________________________________________________________________________________
Signed Date
form updated 8/20/21Student Self-Assessment
Name: _______________________________________________ School: _____________________________
Instructions: To help the Talent Search staff assess your needs and develop a plan of service for you, we need to know
what you think you need. Please read through the following list and indicate whether you feel you have a high need, some
need, or no need, for help or improvement in the following areas:
ACADEMIC SKILLS
English and Writing Skills:
Spelling………………………………………. High Need Some Need No Need
Grammar……………………………………... High Need Some Need No Need
Punctuation…………………………………... High Need Some Need No Need
Organizing your writing……………………... High Need Some Need No Need
Writing essays and reports for classes……….. High Need Some Need No Need
Verbal expression (speaking skills)………….. High Need Some Need No Need
Learning/improving English as a second
language if applicable………………………... High Need Some Need No Need
Reading Skills:
Improving vocabulary……………………….. High Need Some Need No Need
Reading speed………………………………... High Need Some Need No Need
Comprehension (understanding)…………….. High Need Some Need No Need
Retention……………………………………... High Need Some Need No Need
Math Skills:
Basic arithmetic……………………………… High Need Some Need No Need
Basic algebra………………………………… High Need Some Need No Need
Advanced math………………………………. High Need Some Need No Need
Learning and Study Skills:
Time management…………………………… High Need Some Need No Need
Developing good study habits……………….. High Need Some Need No Need
Studying for and taking test………………….. High Need Some Need No Need
Taking notes in class………………………… High Need Some Need No Need
Developing library skills…………………….. High Need Some Need No Need
OTHER
Careers:
Deciding educational goals…………………... High Need Some Need No Need
Exploring career options……………………... High Need Some Need No Need
Identifying career interests…………………... High Need Some Need No Need
Identifying career aptitudes (ability)………… High Need Some Need No Need
Personal Motivations:
Improving school/class attendance…………... High Need Some Need No Need
Studying/doing homework…………………... High Need Some Need No Need
Improving attitude toward school……………. High Need Some Need No Need
Setting goals and priorities…………………... High Need Some Need No Need
Personal Counseling:
Improving interpersonal skills……………….. High Need Some Need No Need
Building self-confidence…………………….. High Need Some Need No Need
Working through a personal problem………... High Need Some Need No Need
Drug or alcohol use or abuse………………… High Need Some Need No Need
College Admissions:
Planning to meet college admissions………… High Need Some Need No Need
Requirements………………………………… High Need Some Need No Need
Identifying and applying for scholarships and
financial aid for college……………………… High Need Some Need No Need
Deciding which college to attend……………. High Need Some Need No Need
Are there other specific academic or personal areas with which you would like assistance or counseling? If yes, please
explain: _______________________________________________________________________________________Student Recommendation
I am recommending that __________________________________________________ be a participant in
the Educational Talent Search Program. This student meets the criterion of:
a) First generation college (neither parent graduated from a 4-year college
b) Low income
c) Has potential of achieving some type of post-secondary education (from 6-month certificate
program to bachelor’s degree).
The applicant would benefit from the Educational Talent Search Program because:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
_________________________________________________________ Date: _____________________
Signature of person completing this form
_____________________________________________________________________
Title or Position
_________________________________________________________________
School or Institution
Any additional comments:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
__________________________________(For Office Use Only)
Date Recommendation ReceivedSTUDENT/PARENT CONTRACT
If selected to participate in Utah Valley University’s Educational Talent Search Program, I
agree to participate to the fullest extent possible in the academic, educational, and social
activities of the program as follows:
• I agree to attend school regularly.
• I agree to attend the monthly ETS meetings held in my school.
• I agree to maintain a 2.5 GPA.
• I agree to work hard and graduate from high school at the end of the 12th grade year or to
graduate early if possible.
• I agree upon graduation from high school that I will attend a college or university in the
fall after my high school graduation as agreed upon initially to participate in the
Educational Talent Search Program.
• I agree to earn a college degree within 6 years following high school graduation. I
understand TRIO staff will follow up/track my progress each year.
____________________________________________________________
Student Signature Date
____________________________________________________________
Parent Signature DateUTAH VALLEY UNIVERSITY ACTIVITY PARTICPATION
AGREEMENT FOR MINORS
MINOR PARTICIPANT: GUARDIAN:
Name: (“Guardian”)
Name: (“Participant”)
Address: (if different than Participant’s)
Address:
Phone Number:
Activity: UVU Talent Search Meetings/Activities
TERMS
This Activity Participation Agreement (the “Agreement”) is entered into as of the last signature date below, by
and between Utah Valley University, a body politic and corporate of the State of Utah (“UVU”), and Guardian.
Guardian acknowledges that this Agreement contains, among other provisions, the following contractual
terms: an assumption of risk, a covenant not to sue, a release of the Guardian and Minor’s claims, and
indemnification obligations. Guardian represents that Participant is under 18 years of age and that Guardian is
fully competent and authorized to sign this Agreement on Participant’s behalf. Guardian gives permission for
Participant to engage in the Activity. In consideration for UVU permitting Participant to engage in the Activity,
Guardian, for Participant, and for their respective heirs, personal representatives, and assigns, agrees as follows:
1. Assumption of Risk. Guardian represents that Participant is qualified, in good health, and in proper
physical condition to participate in the Activity. Guardian acknowledges and understands that the Activity may
include but is not limited to the following: physical activities (e.g., running, jumping, climbing); physical
exertion such as lifting or moving heavy objects; spending extended periods of time outdoors being exposed to
the elements (sun, wind, rain); travel to and from the Activity; and consumption of food and/or beverage.
Guardian acknowledges and understands that Participant may be exposed to certain risks that are inherent in
participation in the Activity. These risks may include but are not limited to such things as incidents related to
the above- mentioned activities, including sprains, broken bones, cuts, bruises, entrapment, temporary or
permanent disability, illness, personal injury, and/or death; adverse weather conditions; exposure to theft and
other criminal activity; allergic reactions to food and drink items; other physical, mental, and emotional injury;
other risks and dangers, whether known or unknown nor reasonably foreseeable. Guardian, on behalf of
Participant, knowingly and voluntarily, accepts, and assumes responsibility for each of these risks and dangers,
and all other risks and dangers that could arise out of, or occur during, Participant’s engagement in the Activity.
2. Covenant Not to Sue: Guardian for him/herself, and on behalf of Participant, agrees that Guardian will
not commence any legal action or lawsuit or otherwise assert any legal claim against UVU and its officers,
directors, employees, and agents seeking relief for any claim, whether or not such claim is released or waived
under this Agreement.
3. Indemnification: Guardian agrees to indemnify and hold UVU and its trustees, officers, directors,
employees, and agents harmless from any and all claims, actions, suits, procedures, costs, expenses, damages
and liabilities, including attorney’s fees, arising out of Participant’s involvement in the Activity and to
reimburse UVU for any such expenses incurred.4. Release of Claims: Guardian for him/herself, and on behalf of Participant, releases and fully discharges UVU, including its trustees, officers, agents, and employees, from any and all claims or causes of action that may be brought by Guardian, Participant, or by any other person (including but not limited to Guardian’s estate, family, successors, heirs, representatives, administrators, and/or assigns), including all liability for damage to personal property, personal injury or loss arising out of or related to Participant’s engagement in the Activity to the fullest extent permitted by law. 5. Severability/Governing Law: Guardian agrees that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of Utah and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The Agreement shall be governed by the laws of the State of Utah, without regard to conflicts of laws principles. Venue for any lawsuits, claims, or other proceedings between the Parties relating to or arising under the Agreement shall be exclusively in the State of Utah. 6. Health Insurance and Consent to Medical Treatment: Should Participant require emergency medical treatment as a result of accident or illness arising during the Activity, Guardian consents to such treatment. Guardian acknowledges that UVU will not provide health and accident insurance for Participant, and Guardian agrees to be financially responsible for any medical bills incurred as a result of emergency medical treatment. 7. Bacterial and Viral Diseases. Guardian understands and acknowledges the highly contagious nature of bacterial and viral diseases including, but not limited to the 2019 novel coronavirus disease (COVID-19) (collectively, the "Disease") and the risk that Participant may be exposed to or contract the Disease, or other infectious diseases, by participating in the Activity. Guardian understands and acknowledges that such exposure or infection may result in serious illness, personal injury, permanent disability, death, or property damage. Guardian understands and acknowledges that this risk may result from or be compounded by the actions, omissions, or negligence of others, including University employees. Guardian understands and acknowledges that while the University has implemented preventative measures to reduce the spread of the Disease, the University cannot guarantee that Participant will not become infected with the Disease, or other infectious diseases, while participating in the Activity and that participating in the Activity may increase Participant’s risk of contracting the Disease. NOTWITHSTANDING THE RISKS ASSOCIATED WITH THE DISEASE, GUARDIAN ACKNOWLEDGES THAT GUARDIAN IS VOLUNTARILY ALLOWING PARTICIPANT TO PARTICIPATE IN THE ACTIVITY WITH KNOWLEDGE OF THE DANGER INVOLVED. GUARDIAN AGREES TO ACCEPT AND ASSUME ALL RISKS OF PERSONAL INJURY, ILLNESS, DISABILITY, DEATH, OR PROPERTY DAMAGE RELATED TO THE DISEASE, ARISING FROM PARTICIPANT’S PARTICIPATING IN THE ACTIVITY OR ENGAGING IN ANY SIMILAR ACTIVITY AT THE UNIVERSITY, WHETHER CAUSED BY THE NEGLIGENCE OF THE UNIVERSITY OR OTHERWISE. Acknowledgment: I am the parent or legal guardian of the Participant. I understand the legal consequences of signing this document, including (a) releasing UVU and its officers, directors, employees, and agents from all liability on my and the Participant’s behalf, (b) promising not to sue on my and the Participant’s behalf, and (c) assuming all risks of the Participant’s participation in this Activity, including travel to, from and during the Activity. I give my consent for Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of Participant as described in this document. I agree to be bound by the terms of this document. I have read this two-page document, and I am signing it freely and voluntarily. ___________________________________________________________________________ Signature of Guardian Date: ________________________________________________________________________________________ Signature of Minor Participant Date:
Risks & Hazards Statement of Understanding and Release
The undersigned hereby acknowledges and agrees to the following statements:
1. I, (herein participant) expect and intend to participate in college site visits to be sponsored by Utah Valley
University, following the execution of this Statement of Understanding and Release.
2. In consideration of the College’s sponsorship and direction of the activity, and his/her participation, participant
hereby states that he/she has read and fully understands the Risks and Hazard Statement which is included herein and
releases and discharges the State of Utah, the University, and their officers, agents and employees and volunteers from any
and all claims, damages, losses or injuries connected therewith, including, but not limited to, any loss, damage or injury
suffered by participant or others, as a result of failure to obey safety regulations or resulting from the exercise of the activity
coordinator or other individuals acting in good faith response to emergencies and exigencies on this activity whether at the
University or any other location.
3. Participant further agrees and understands that during the activity, he/she will be under the direction of the instructor
or director approved by Utah Valley University and specifically agrees to comply with all reasonable directions and
instructions by the instructor or director during the course thereof.
4. Participant understands and acknowledges that there are specific risks of injury to person and/or property that are
associated with activity, including risks related to travel hazards, terrain, weather, eating and sleeping arrangements, and
other circumstances. Participant specifically assumes the risks associated with such conditions.
5. Participant certifies and represents that if he/she drives a personal vehicle to, from, and/or during the activity, the
vehicle must be covered throughout the period of the activity by a motor vehicle liability insurance policy, currently in
effect, with limits of coverage and liability that satisfy the requirement of the Utah Motor Vehicle Safety Responsibility Act,
1952 Utah Code Anno. 41-12-1 et seq.
6. Participant understands and acknowledges that Utah Valley University assumes no liability for personal injuries or
property damages to participants or to third parties arising out of activity, except to the extent that such liability is imposed
by law. Participant agrees to indemnify and save harmless, the State of Utah, the University and its officers, agents,
employees, and volunteers from any claim or liability arising out of the acts or omissions of the participant during any such
activity, subject to any limitations or restrictions against such indemnification that are imposed by law.
7. Participant understands and acknowledges that there may be unsupervised times before, during, or after the hours of
the sponsored activity. It is understood that during this time participants will conduct themselves as responsible individuals
as well as adhere to all applicable laws and statutes in effect. Failure to comply with this section may result in physical harm
or property loss due to hazards beyond the University’s control. Failure to comply may also result in expulsion from the
activity. The University will not be responsible for any such acts nor any costs resulting from expulsion from the activity.
8. The participant hereby understands that he/she should arrange for appropriate personal health insurance coverage
(e.g. hospital/medical insurance, student health insurance, etc.) during the period of the activity. The participant agrees and
understands that he/she will be personally responsible for any medical costs incurred during this activity.
Date: ____________________________ Signed Participant: _______________________________________
(If participant is under age 18, you must have the signature of at least one parent or of a legal guardian)
Date: ____________________________ Signed:_________________________________________________
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