Personal Data Form

Please print this form or download a black and white .pdf, complete and mail with applicant's and parent's materials as described in Application Procedures

Applicant's name _______________________________________

Birthdate _____/_____/___________

School ___________________________ Current Grade _________

Parent or guardian _____________________________________

Home address ___________________________________________

City _________________________ State _________ Zip __________

Phone: Home ___________________ Work___________________ Cell ___________________

E-mail ______________________________________
(for Expeditions business use only)

Emergency contact ______________________________________

Phone __________________________________________________

[] Please send me information on before-class care.

[] Please send me information about the noon van to OSU KidSpirit.

[] Please send me information about possible bus transportation from out-of-town.

For New Applicants Only

Criterion a, b, or c must be verified by a TAG coordinator, school counselor, or school administrator.
Applications received without supporting evidence will not be processed.

Indicate pertinent information:

Test Name: _____________________________________________

National Percentile:Cognitive Total ___________ Date administered _________________

Test Name: _____________________________________________

National Percentile:Math Total ______________ Date administered _________________

Test Name: _____________________________________________

National Percentile:Reading Total ____________ Date administered _________________

School representative's signature __________________________________

Position __________________________________

[] Criterion d applicant: completed Reference Forms attached.

[] Home school student: copy of most recent test results attached.