Revised: September 28, 2017

EDUCATIONAL TALENT SEARCH PROGRAM APPLICATION Phone: (713) 221-8992 Fax: (713) 223-7432 E-mail: talentsearch@uhd.edu Website: www.uhd.edu/talent

Please print clearly

TELL US ABOUT YOURSELF AND YOUR FAMILY Student Information:

School: Grade Level: Today’s Date:

Email Address:

Student’s Name: Student ID #: LAST FIRST MIDDLE

Address: NUMBER AND STREET APT. NO. CITY STATE ZIP CODE

How many years have you lived at your current address?

Home Phone #: Cell Phone #: Parent’s Cell Phone #:

Parent’s Email Address: ____________________________________________________________________________________

Age: Sex: Female Male Race:

Date of Birth: / / Place of Birth: STATE OR COUNTRY

Are you on free or reduced lunch at school? (Please answer yes or no) __________________ Emergency Contact Information: ___________________________ ________________________________ ___________________________ Name Relationship to Student Phone Number ___________________________ ________________________________ ___________________________ Name Relationship to Student Phone Number Student Citizenship Status: (You must be a U.S. citizen of an eligible non-citizen to be a member of this program.)

Are you a U.S. citizen or an eligible non-citizen? Yes No Alien Registration #: (Required if an eligible non-citizen)

Student’s Social Security # / Número de seguro social del estudiante: __________________________________________ (Required Information) / (Información Requerida) First Generation Status: Does either parent/guardian you live with have a bachelor's degree (four-year college/university degree)? Yes No College Attended:_________________________________________ Name of Parent/Guardian:_________________________ College Attended:_________________________________________ Name of Parent/Guardian:_________________________ (Please turn page over)

Revised: October 17, 2017

Income Status (IS): ALL QUESTION MUST BE ANSWERED:

How many of your family members live at home with you, including yourself that your parent/guardian provide support (food, clothing, shelter, money)? Please list their names, ages, and their relationship to you. (Including parent/guardian and applicant).

Name Relationship to you Age Name Relationship to you Age

Indicate the parent(s)/guardian(s) you lived with the most during the past year. Check only one and list their names on the lines provided below:

Mother and father Mother Father Mother and stepfather Father and stepmother Other (please specify relationship)

First Name Last Name First Name Last Name

TAXABLE INCOME: (Find on your 1040EZ, 1040, or 1040A Tax Forms) "Taxable income" is the total family income after deductions. “Ingreso imponible” es el ingreso total de la familia después de deducciones. Your taxable income is found on: Line 06 on the 1040EZ Line 43 on the 1040 Line 27 on the 1040A $ (REQUIRED INFORMATION)/ (INFORMACION REQUERIDA) This form will be returned if this question is not answered. Este formulario se devolverá si no se responde a esta pregunta. *It is not unusual for this to be a small number in comparison to your total income.

NON-TAXABLE INCOME: Does your family receive Social Security/Seguro Social? Yes No Does your family receive Welfare/Asistencia Social? Yes No Does your family receive AFDC/Ayudas para familias con hijos a cargo? Yes No Does your family receive Food Stamps (SNAP)/Estampillas de Comida (SNAP)? Yes No Does your family receive Disability/Pensión de Incapacidad? Yes No Does your family receive Unemployment/Desempleo? *Please submit a copy of your latest award letter for verification of nontaxable income such as: welfare, food stamps, AFDC, social security, disability, etc.

Yes No

Participation in the Educational Talent Search Program is completely voluntary. Though we would hope to have you stay in the program through college enrollment, you have the right to withdraw from the program at any time without penalty.

I certify that the information on this application is correct to the best of my knowledge. Student’s Signature Date

Parent/Guardian’s Signature Date

Phone: (713) 221-8992 Fax: (713) 223-7432 Email: talentsearch@uhd.edu Website: www.uhd.edu/talent

NEEDS ASSESSMENT Please Print

Name School Grade Date

Student ID Number _______________________

1. What do you like most about yourself? 2. What do you plan to do after you graduate from high school? Please check only one.

I don’t know Go to college Get a job Join the military Other

3. Do you have a family member in the military? Yes No

4. Circle the grade(s) that you earned most last year. A B C D F 5. Are you satisfied with your grades? Yes No 6. Do you believe that you could make better grades? Yes No 7. Are you having difficulty with or failing any courses? Yes No

If yes, which courses?

8. Do you need tutoring for any course(s)? Yes No

If yes, please list course(s):

9. Do you have any personal or family problems you want to discuss? Yes No 10. Do you need to meet with me privately to discuss special concerns or needs? Yes No 11.

What type of career(s) do you want to pursue?

I don’t know

12. What type of educational preparation do you need for your chosen I don’t know 4 years of college career? (Check one) 2 years of college More than 4 years

13. What college campuses have you visited? None 14.

What college/university do you want to attend? I don’t know

15. Have you requested information from any colleges or technical schools? Yes No

If yes, please list: 16. What is the PSAT? I don’t know Have you taken the PSAT? Yes No If yes, date taken: 17.

What is the SAT or the ACT? I don’t know

18. Have you taken the SAT? Yes No If yes, date taken:

19. Have you taken the ACT? Yes No If yes, date taken: 20.

What is the FAFSA?

I don’t know

21. a) Name three types of financial aid for college

b) What is financial literacy? _______________________________________________________________________________

(Please turn page over)

Revised: September 28, 2017

Career Advisement School Transition Advisement Course Selection Advisement Personal Development/Advisement Public Assistance Referral Major/College Selection Advisement Study/Test-taking Skills Development Mentoring Test Application/Waiver PSE Opportunities Advisement Cultural Enrichment School Reentry Advisement Financial Aid Literacy/ Advisement/ Info. PSAT, SAT, ACT, &/or TSI Info. Campus Tours/College Information Tutorial Assistance Other:

Do you work after school or on weekends?

Yes

No Are you enrolled in the ROTC?

Yes

No Do you want the Educational Talent Search Program to help you to graduate from high school and go to a college or a technical/vocational school?

Yes

No

Are you a member of the Lone Star College Talent Search or Upward Bound Program?

Yes

No

Please list the names of all programs, clubs, or organizations you belong to at your current school. Please tell us something about yourself (hobbies, dreams, extracurricular activities, etc.) and why you want to become a member of the Educational Talent Search Program.

IF YOU ARE A MIDDLE SCHOOL STUDENT, PLEASE SKIP THIS SECTION. 1. Have you passed all sections on STAAR-EOC? Yes No

If no, please list the sections you have not passed:

2. What is the Texas Success Initiative? I don’t know

3. Have you taken the THEA, Compass, Asset, or Accuplacer? Yes No

If yes, please specify which test(s) you have taken:

4. What endorsement(s) will you be taking? STEM Business & Industry Public Services Arts & Humanities

Multidisciplinary Studies I don’t know

5. Have you completed the FAFSA? Yes No Student's Signature Date Signature of ETSP Advisor Date

22. Place a check by at least 3 items in which you think you will need assistance to you accomplish your educational and career goals.

Applicant’s/Child’s Assent Form I, ______________________________________________________________________________, have been informed that: (Please Print Your Full Name) Carrie Hays, Director of the Educational Talent Search Program (ETSP) at the University of Houston-Downtown, has requested the submission of my application to be considered for participation or continuation in the ETSP. I understand that the purpose of the Educational Talent Search Program is to assist me with successfully completing secondary school and enrolling in the postsecondary education institution of my choice.

I understand that my involvement in this program is completely voluntary and all services are free. In addition, if I choose not to participate or to withdraw from the program at any time, there will be not a penalty. Program acceptance or continuation will entail the following:

a. Meeting with an assigned ETSP Advisor for college prep advisement/workshops at my designated school during an elective class for approximately 30 to 60 minutes once a month during each school year until high school graduation.

b. Attending free college campus and cultural enrichment fieldtrips c. Academic tutoring after school: small group tutoring at my school, local library or at the University of Houston-Downtown and

online and/or telephone tutoring. d. Assistance with college/scholarship searches and completion of applications e. Assistance with registration/preparation for college entrance examinations (PSAT, SAT, ACT, etc.) during and/or after school. f. Submission and/or access to school transcripts, grade reports, test records, free/reduced lunch information and educational or

personal data related to program services. g. Non-credit Summer Academic Math Enrichment at the University of Houston-Downtown for rising 8th, 9th and 10th graders. h. Collection of data to complete the program’s annual performance report required by the Department of Education. All of the

data collected may be published but my name will never be used. I understand that there are no foreseeable risks to me if I agree to participate or continue in this program. The benefits of my participation or continuation in this program are free college prep, academic tutoring and financial aid information and services to support my secondary and postsecondary school endeavors. I know that if I have any questions concerning the Educational Talent Search Program at the University of Houston-Downtown or my participation in the program, I can call Carrie Hays at (office) 713-221-8978, or email her at haysc@uhd.edu. I understand and all of my questions have been answered. Please initial only one and return this form to the ETSP Advisor at your school. ______ I want to participate or continue in the UHD Educational Talent Search Program. ______ I do not want to participate or continue in the UHD Educational Talent Search Program. ____________________________________________________________________________________________________ Signature of Applicant Date Age D.O.B. School Grd. Level Person explaining the program: Signature ____________________________________________ Date ______________ Any questions regarding your rights as a participant of the UHD Educational Talent Search Program may be addressed to the UHD Committee on Standards through its current Chair, Dr. Kristin Anderson at 713-221-8510 or email at andersonk@uhd.edu. All federal grant projects that are carried out at the University of Houston-Downtown are governed by requirements of the University and the Federal Government.

Formulario de Asentimiento del Solicitante/Estudiante Yo, ___________________________________________________________________________, he sido informado de que: (Por favor, escriba su nombre completo) Carrie Hays, Directora del Programa de Búsqueda de Talentos Educativos (ETSP) en la Universidad de Houston-Downtown, ha solicitado la presentación de mi solicitud para ser considerada para la participación o continuación en el ETSP. Entiendo que el propósito del Programa de Búsqueda de Talento Educativo es ayudarme con terminar con éxito la escuela secundaria y matricularme en la institución de educación postsecundaria de mi elección. Entiendo que mi participación en este programa es completamente voluntaria y todos los servicios son gratuitos. Además, si elijo no participar o retirarme del programa en cualquier momento, no habrá una penalidad. La aceptación o continuación del programa implicará lo siguiente:

a. Encuentro con un Asesor ETSP asignado para la preparación universitaria asesoría / talleres en su escuela designada durante una clase electiva durante aproximadamente 30 a 60 minutos una vez al mes durante el año escolar hasta la graduación de secundaria.

b. Asistir excursiones gratuitas de la universidad y enriquecimiento cultural. c. Tutoría académica después de clases: tutoría en grupos pequeños en su escuela, biblioteca local o en la Universidad de

Houston-Downtown tutoría y en línea y / o teléfono. d. Asistencia en búsquedas de universidad / becas y realización de aplicaciones. e. Asistencia con el registro / preparación para los exámenes de ingreso universitario (PSAT, SAT, ACT, etc.) durante y / o

después de la escuela. f. Presentación y / o el acceso a transcripciones escolares, reportes de calificaciones, registros de pruebas, información de

almuerzo gratis / reducido y datos educativos o personales relacionadas con los servicios del programa. g. Enriquecimiento Académico de Matemáticas en la Universidad de Houston-Downtown durante el verano para el aumento

octavo grado, noveno y décimo en cual ningún crédito es acreditado. h. La recopilación de datos para completar el informe de ejecución anual del programa requerido por el Departamento de

Educación. Todos los datos recogidos pueden ser publicados, pero el nombre de su hijo nunca se utilizarán. Entiendo que no hay riesgos previsibles al participar o continuar en este programa. Los beneficios de la participación o continuación en este programa son de preparación universitaria gratuita, tutoría académica y servicios de información y asistencia financiera para apoyar los esfuerzos de secundaria y post-secundaria. Yo sé que si tengo alguna duda sobre el Programa de Búsqueda de Talento Educativo de la Universidad de Houston-Downtown o mi participación en el programa, puedo llamar a Carrie Hays (oficina) 713-221-8978 o por correo electrónico a haysc@uhd.edu. Entiendo y todas mis preguntas han sido contestadas. Por favor escriba solamente una y devuelva este formulario al Asesor de ETSP en su escuela. ______ Quiero participar o continuar en el Programa de Búsqueda de Talento Educativo de UHD. ______ No quiero participar ni continuar en el Programa de Búsqueda de Talento Educativo de UHD. ___________________________________________________________________________________________________________ Firma del Estudiante Fecha Escuela Edad Fecha de Nacimiento Grado Actual Persona que explica el programa: Firma: ______________________________________ Fecha: _____________________ Cualquier pregunta relacionada con sus derechos como padre / tutor de un participante del Programa Educational Talent Search UHD pueden dirigirse al Comité UHD sobre normas a través de su actual Presidente, Dr. Kristin Anderson al 713-221-8510 o al correo electrónico andersonk@uhd.edu. Todos los proyectos de subvención federal que se llevan a cabo en la Universidad de Houston-Downtown se gobiernan por los requisitos de la Universidad y del Gobierno Federal.

For office use only:

Phone: (713) 221-8992 Fax: (713) 223-7432 Email: talentsearch@uhd.edu Website: www.uhd.edu/talent

Revised: September 28, 2017

RELEASE OF STUDENT INFORMATION

has permission to release the information listed below on

School/Agency/Test Center Name

Last Name First Name MI Age Date of Birth Grade

to the University of Houston-Downtown Educational Talent Search Program. This information may be used in determining Talent Search eligibility and participation. In addition, the Talent Search Program has permission to release information to the above mentioned school/agency or test center that would be instrumental in the participant’s educational, personal or social development. This permission is valid for the duration of student’s participation in the program, unless sooner revoked in writing

by the student and/or parent/guardian. All information will be kept confidential. • Transcripts • Grade Reports • Test Records • Free or Reduced Lunch Information • Other Educational or Personal Data

Participation in the Educational Talent Search Program is completely voluntary. Though we would hope to have your child stay in the program through college enrollment, you have the right to withdraw him/her from the program at any time without penalty.

Please Print Parent/Guardian Name

Address

City

State

Zip Code

Home Phone #

Cell Phone #

Work Phone #

Parent/Guardian Email Address

Student’s Signature Date Signature of Parent/Guardian Date

For office use only:

Phone: (713) 221-8992 Fax: (713) 223-7432 Email: talentsearch@uhd.edu Website: www.uhd.edu/talent

Revised: September 28, 2017

LIBERACIÓN de INFORMACIÓN ESTUDIANTIL

Tiene mi permiso para otorgar la información descrita debajo

(Escuela, Agencia, Centro de Examen) Apellido Nombre Inicial Edad Fecha de Nacimiento Grado

a la Universidad de Houston-Downtown Búsqueda de Talento Educativo para que pueda ser utilizada en determinar la elegibilidad y participación en Talent Search. En adición, el Programa de Talent Search tiene mi permiso para ceder información a la escuela, agencia, o centro de examen mencionado arriba para el desarrollo educacional, personal, o social del estudiante. Este permiso es válido durante la participación del estudiante en el programa a menos que el permiso sea revocado por escrito por el estudiante o el padre. Toda información se mantendrá confidencial.

• Expediente de calificaciones • Calificaciones por semestre • Calificaciones de los exámenes • Información de Comida Gratis o Reducida en precio • Cualquier otra información educacional o personal

La participación en el Programa de Búsqueda de Talento Educativo es completamente voluntaria. Aunque esperamos que su hijo permanezca en el programa a través de la inscripción en la universidad, usted tiene el derecho de retirarlo del programa en cualquier momento sin penalidad.

Por Favor Imprimir

Nombre del Padre/ Tutor:

Dirección

Ciudad

Estado

Código Postal

Número de Teléfono de casa

Número Celular

Numero del Trabajo

Correo electrónico del padre/tutor

Firma del Estudiante Fecha Firma del Padre Fecha

Parent Informed Consent Form

I, ______________________________________________________________________________, have been informed that: Full Name of Parent/Guardian (Please Print) Carrie Hays, Director of the Educational Talent Search Program (ETSP) at the University of Houston-Downtown, has requested the submission of my son’s/daughter’s/ward’s application to be considered for participation or continuation in the ETSP. I understand that the purpose of the Educational Talent Search Program is to assist my son/daughter/ward with successfully completing secondary school and enrolling in the postsecondary education institution of his/her choice.

I understand that my child’s involvement in this program is completely voluntary and all services are free. In addition, if I choose not to have my son/daughter/ward apply, participate or to withdraw from the program at any time, there will be not a penalty. Program acceptance or continuation will entail the following:

a. Meeting with an assigned ETSP Advisor for college prep advisement/workshops at his or her designated school during an elective class for approximately 30 to 60 minutes once a month during each school year until high school graduation.

b. Attending free college campus and cultural enrichment fieldtrips c. Academic tutoring after school: small group tutoring at his/her school, local library or at the University of

Houston-Downtown and online and/or telephone tutoring. d. Assistance with college/scholarship searches and completion of applications e. Assistance with registration/preparation for college entrance examinations (PSAT, SAT, ACT, etc.) during

and/or after school. f. Submission and/or access to school transcripts, grade reports, test records free/reduced lunch information

and educational or personal data related to program services. g. Non-credit Summer Academic Math Enrichment at the University of Houston-Downtown for rising 8th, 9th and

10th graders. h. Collection of data to complete the program’s annual performance report required by the Department of

Education. All of the data collected may be published but your child’s name will never be used. I understand that there are no foreseeable risks to my son/daughter/ward if I agree to let him/her participate or continue in this program. The benefits of my son’s/daughter’s/ward’s participation or continuation in this program are free college prep, academic tutoring and financial aid information and services to support my child’s secondary and postsecondary school endeavors. I know that if I have any questions concerning the Educational Talent Search Program at the University of Houston-Downtown or my son’s/daughter’s/ ward’s participation in the program, I can call Carrie Hays at (office) 713-221-8978 or email her at haysc@uhd.edu. I give consent for my son/daughter/ward, ____________________________________________________, to participate. Please Print Son’s/Daughter’s/Ward’s Name ____________________________________________________________________________________________________ Signature of Parent/Guardian Date Phone Number If you agree to your child’s participation in the UHD ETSP, please provide the following information. Please Print! Son’s/Daughter’s/Ward’s Name Current School Age D.O.B. Current Grade Level Any questions regarding your rights as the parent/guardian of a participant of the UHD Educational Talent Search Program may be addressed to the UHD Committee on Standards through its current Chair, Dr. Kristin Anderson at 713-221-8510 or email at andersonk@uhd.edu. All federal grant projects that are carried out at the University of Houston-Downtown are governed by requirements of the University and the Federal Government.

Formulario de Consentimiento Informado de los Padres

Yo, ___________________________________________________________________________, he sido informado de que: Nombre Completo del Padre / Tutor (letra de imprenta) Carrie Hays, Directora del Programa de Búsqueda de Talento Educativo (ETSP) en la Universidad de Houston-Downtown, ha solicitado la presentación de aplicación / de la pupila de mi hijo / hija para ser considerado para la participación o continuación en el ETSP. Entiendo que el propósito del Programa de Búsqueda de Talento Educativo es ayudar a mi hijo / hija / pupilo para completar con éxito la escuela secundaria y matricularse en la institución de educación postsecundaria de su / su elección. Entiendo que la participación de mi hijo en este programa es voluntaria y todos los servicios son gratuitos. Además, si decido no tener a mi hijo / hija / pupilo aplicar, participar o retirarse del programa en cualquier momento, no habrá una sanción. Aceptación o continuación del programa supondrán los siguientes:

a. Encuentro con un Asesor ETSP asignado para la preparación universitaria asesoría / talleres en su escuela designada durante una clase electiva durante aproximadamente 30 a 60 minutos una vez al mes durante el año escolar hasta la graduación de secundaria.

b. Asistir excursiones gratuitas de la universidad y enriquecimiento cultural. c. Tutoría académica después de clases: tutoría en grupos pequeños en su escuela, biblioteca local o en la Universidad de

Houston-Downtown tutoría y en línea y / o teléfono. d. Asistencia en búsquedas de universidad / becas y realización de aplicaciones. e. Asistencia con el registro / preparación para los exámenes de ingreso universitario (PSAT, SAT, ACT, etc.) durante y / o

después de la escuela. f. Presentación y / o el acceso a transcripciones escolares, reportes de calificaciones, registros de pruebas, información de

almuerzo gratis / reducido y datos educativos o personales relacionadas con los servicios del programa. g. Enriquecimiento Académico de Matemáticas en la Universidad de Houston-Downtown durante el verano para el aumento

octavo grado, noveno y décimo en cual ningún crédito es acreditado. h. La recopilación de datos para completar el informe de ejecución anual del programa requerido por el Departamento de

Educación. Todos los datos recogidos pueden ser publicados, pero el nombre de su hijo nunca se utilizarán. Entiendo que no hay riesgos previsibles a mi hijo / hija / pupilo si estoy de acuerdo para dejarlo / ella participar o continuar en este programa. Los beneficios de la / participación o continuación de la pupila de mi hijo / a en este programa son de preparación universitaria gratuita, tutoría académica y servicios de información y asistencia financiera para apoyar los esfuerzos de secundaria y post-secundaria de mi hijo. Yo sé que si tengo alguna duda sobre el Programa de Búsqueda de Talento Educativo de la Universidad de Houston-Downtown o participación de mi hijo / hija / pupilo en el programa, puedo llamar a Carrie Hays (oficina) 713-221-8978 o por correo electrónico a haysc@uhd.edu. Doy permiso para que mi hijo / hija / pupilo, ______________________________________________________________, a participar.

Por favor escriba el Nombre de su Hijo / Hija ___________________________________________________________________________________________________________ Firma del Padre / Tutor Fecha Teléfono Si está de acuerdo con la participación de su hijo en el ETSP UHD, por favor proporcione la siguiente información. Por favor escriba! ___________________________________________________________________________________________________________ Nombre de su Hijo / Hija Escuela Edad Fecha de Nacimiento Grado Actual Cualquier pregunta relacionada con sus derechos como padre / tutor de un participante del Programa Educational Talent Search UHD pueden dirigirse al Comité UHD sobre normas a través de su actual Presidente, Dr. Kristin Anderson al 713-221-8510 o al correo electrónico andersonk@uhd.edu. Todos los proyectos de subvención federal que se llevan a cabo en la Universidad de Houston-Downtown se gobiernan por los requisitos de la Universidad y del Gobierno Federal.

Form No. OGC-SF-2003-02

University of Houston-Downtown AUTHORIZATION FOR USE OF IMAGE, VOICE, PERFORMANCE, ARTWORK OR LIKENESS

I, (printed name)__________________________________________________ permit and authorize the University of Houston - Downtown (the "University" - a component institution of the University of Houston System) and its employees, agents, representatives, contractors, and personnel who are acting on behalf of the University to create and/or obtain and use my photograph, my voice or quotes/excerpts of my written or verbally expressed words, my artwork or a photograph of my artwork, my name, alias, or biographical information, a video and/or audio recording or other likeness of myself (hereinafter collectively referred to as "My Likeness") for purposes related to the educational mission of the University, including instructional and/or educational purposes, publicity, marketing, and promotion of the University and its various programs without compensation to me. I understand My Likeness may be copied/reproduced and distributed by means of various media, including, but not limited to, video presentations, simultaneous television broadcast/rebroadcast, radio transmission/retransmission, news releases, mail-outs, e-mails, billboards, signs, brochures, placement on websites and/or other electronic delivery, publication, display, or promotion on any and all other media, and I further understand that My Likeness may be subject to reasonable modification or editing. I acknowledge that the University has the right to make one or more photographs, audio recordings, videotape or disk presentations, or other electronic reproductions of My Likeness in accordance with this Authorization for Use of Image, Voice, Performance, Artwork, or Likeness (hereinafter sometimes referred to simply as "this Authorization"). I waive any right to inspect or approve the finished product or material in which the University may eventually use My Likeness.

I relinquish and give the University all rights, title and interests in and to My Likeness, including any copyright therein. This Authorization shall be binding upon my heirs, successors, assigns, and legal representations.

I understand that, although the University will endeavor to use My Likeness in accordance with standards of good judgment, the University cannot warrant or guarantee that any further dissemination of My Likeness will be subject to University supervision or control. Accordingly, I release the University from any and all liability related to the dissemination, reproduction, distribution, and/or display of My Likeness in print or any and all other media, and any alteration, distortion or illusionary effect of My Likeness, whether intentional or otherwise, in connection with said use. I also understand that I may not withdraw my permission for use of My Likeness which was granted in this Authorization.

I have read and understand the conditions of this Authorization for Use of Image, Voice, Performance, Artwork, or Likeness.

______________/________________ _________________________________Student's Signature Date Age (if minor)

_______________________________ _________________________________Student's Name (Please Print) Phone

__________________________________ _______________________________ Address City/State/Zip

CONSENT OF PARENT/LEGAL GUARDIAN REQUIRED IF ABOVE INDIVIDUAL IS A MINOR. I am the parent and/or guardian of the above minor and hereby consent and agree to the foregoing terms and provisions on his or her behalf.

_______________________________ _________________________________Parent's Signature Date

_______________________________ _________________________________Parent's Name (Please Print) Phone

__________________________________ _______________________________ Address City/State/Zip

Note: Modification of this Form requires approval of OGC

Office of the General Counsel Authorization of Use Image OGC-SF-2003-02 Revised 07.29.09 Page 1 of 1