Application Request for Services

Name:
Sex:	Male Female
Address: Street Address
City
Zip
County	(If you live outside these 6 Kentucky Counties, you are out of our service area and cannot be served by the EKU Educational Talent Search Program.)
Phone
E-mail Address
Current Grade Level (6th thru 12th) or (Out of School Adult)
Name of Current School

If Not Currently Enrolled In School, Please Complete Below Section
Last Grade Completed:
Date last grade completed:
Have you taken the GED:	Yes No
Date Received GED:
Did you graduate from high school?	Yes No
High School Graduation Date: