<p> Summer Enrichment Program South Central Ohio ESC Scholarship </p><p>PARENT/GUARDIAN INFORMATION AND RELEASE FORM This Parent Release Form together with the Nomination Form and the Student Application Form must be submitted by March 15, 2010 to Sharee Price, Gifted Services Coordinator at the ESC, in order for the student to be considered for this scholarship. Applications will not be accepted after this date! Student Name ______School ______Grade Level ______Parents’ Names ______Address ______Phone ______Summer Enrichment Program of Interest (Name of College & Program): ______In what ways do you feel this Summer Enrichment opportunity will benefit your son or daughter?</p><p>______</p><p>______</p><p>______</p><p>______</p><p>____</p><p>Total Cost of Program: ______</p><p>Total amount being requested: ______</p><p>How many people live in your household? ______</p><p>Are there any extenuating circumstances that we should consider when looking at student financial need? If so, please explain. </p><p>______</p><p>______</p><p>______</p><p>______</p><p>____ Continue to back </p><p>Has your son/daughter applied for the OAGC Student Scholarship Award? ______(If not, please go to www.scoesc.org and click on Gifted Services, then follow the links to Summer Programs. You will find a link to OAGC’s site here.) If you have not already done so, please make application for this scholarship award. You will need to see your guidance counselor to find out who your district’s OAGC member is, so he/she may sign as your nominator. </p><p>Is it your intent to apply for any other financial assistance in order for your son/daughter to participate in this program? ______If so, where? ______</p><p>From the latest federal income tax return, indicate the range of taxable income for your household  Less than $29,999  $30,000 - $49,999  $50,000 - $69,999  Over $70,000 </p><p>PHOTO RELEASE I give my permission for any pictures that are taken containing my child to be used for future promotional purposes by the South Central Ohio Educational Service Center. </p><p>LIABILITY RELEASE Upon applying for entry into any of the Summer Enrichment Programs, I hereby, for myself or my other representatives, waive and forever release any and all rights and claims against the South Central Ohio Educational Service Center for injuries, damages, losses, and/or expenses which I may suffer as a result of attending, participating in, practicing for, or traveling to or from the Summer Enrichment Program. </p><p>PERMISSION TO PARTICIPATE I hereby certify that I have reviewed and understand the information in this packet and that the information on this form is true and correct to the best of my knowledge and belief and I give my son/daughter permission to participate in the Summer Enrichment experience at his/her chosen college. </p><p>Parent or Guardian Name (Printed) ______</p><p>Parent or Guardian Signature ______This form may be faxed to 353-4392 or you may mail it to: Sharee Price, SCOESC, 411 Court Street, Room 108, Portsmouth, Ohio 45662</p>