DHS-5339-ENG   7-24 (1.1.2)

CHILD SAFETY AND PERMANENCY DIVISION

Education and Training Voucher (ETV) Program Application and Renewal

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Welcome to the ETV Program

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Student Information

Enter name used:

Current mailing address

Contact information

Contact person who can always get in touch with me

Race/ethnicity information (optional - check all that apply)

Placement History

Fill in the name and contact information of the person that assisted you.

I am over age 18 and in extended foster care (EFC) (ages 18 to 21) OR planning to continue in EFC after age 18.

Post Secondary Education

Authorization for Release of Information

I have read this entire form and I understand its contents. I also understand that if I do not consent to give protected information or if I withdraw my consent, that my application cannot be processed and I will not receive an Education and Training Voucher (ETV).

Effect of signing this form

By checking the box below I authorize:

  • The Minnesota Department of Children, Youth, and Families (DCYF) and the Minnesota Office of Higher Education (OHE) to exchange my non-public information and protected information for the purposes of coordinating application for the Education and Training Voucher program, and the Fostering Independence Higher Education Grant program, and for DCYF to share the data with Youthprise.
  • DCYF and OHE to exchange ETV program eligibility, ETV award information, information on foster care placement including, but not limited to, extended foster care benefit information, and school certification information including the cost of attendance, financial aid award and satisfactory academic progress, and for DCYF to share the data with Youthprise.
  • DCYF and Youthprise to exchange my personal information for the purposes of administering the ETV program. 
  • DCYF and Youthprise to exchange information regarding my school status and issues that may impact my ability to remain in my post-secondary educational program.  
  • DCYF and Youthprise to share my eligibility for the ETV program with post-secondary educational program officials.
  • DCYF and Youthprise to verify with the agency responsible for my placement my foster care status.
  • DCYF, Youthprise, my social worker, probation officer, foster parent/caregiver, and post-secondary education program may exchange information about my foster care status, ETV application/award/budget/expenses/payments, academic progress and issues interfering in my progress, educational program support service and transcripts. 
  • Youthprise to exchange pertinent information with my landlord and county/tribal agency financial worker regarding my school status, rental payments/issues with my housing, and other issues that may impact my ability to remain in my post-secondary school educational program.
  • DCYF, Youthprise and my post-secondary educational programs financial aid office to exchange information about my financial aid and ETV expenses and payments.
  • DCYF, Youthprise and my post-secondary educational programs business office to exchange information about my attendance.
  • DCYF, Youthprise and my post-secondary educational programs Registrars office to exchange information about my enrollment status and academic progress.

Authorization expiration date

The authorization to release my private information ends one year from the date this authorization form is signed.

Participation Agreement

  • I acknowledge that I have reviewed a copy of the Notice of Privacy Practices and that I understand its purposes and contents.
  • I declare that I have looked over my answers and believe that they are all true and correct to the best of my knowledge.
  • I agree to participate in the program and to meet the following requirements
    • Respond immediately to mail, emails and messages from ETV staff regarding my application and voucher. ETV staff will make two attempts to contact you. If you do not respond within one week after the second attempt at contact, you will forfeit your ETV.
    • Maintain an active email account. Free email accounts are available from many sources, and can be accessed from any public or school library. If you are unable to access your email for longer than two weeks, notify ETV staff and let them know when you will have access to your email account again.
    • Submit a transcript for each quarter/semester completed to continue to access your ETV funds.
    • Maintain a 2.0 or better grade point average at the end of each school year to continue to apply for an ETV. Students with less than a 2.0 grade point average should contact ETV staff as soon as possible to discuss their grades and to develop an academic plan.
    • Complete a program orientation before you can use your ETV funds.
  • I must notify ETV staff if the following occurs
    • I move, change my telephone number, email or any other contact information.
    • Change my name.
    • I withdraw from any classes or stop attending school.
    • I am placed on academic probation.
    • My financial situation changes after I have been awarded an ETV.
    • My financial aid is terminated.
    • I leave or I am discharged from extended foster care past age 18.

School Year Budget

I will be attending school in the following months during the school year of: (check all that apply)

Expenses you will have during this school year

See the Expense Guidelines for more detailed information on each expense for which ETV funds can be used.

All listed expense and financial aid fields must have a numeric value of "0" or an actual expense amount. Enter amounts only for the months you will attend school.

Post-secondary school expenses

Child care expenses

Housing and personal expenses (for the entire ETV award year)

Transportation to and from school

Financial Aid

Enter amounts only for the months you will attend school.

Attachments

Attach the following documents to this application. If you are saving the application for later, do not add attachments - they will not be saved.

Required supporting documents

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        Submit or save this application

        Information that identifies you will be removed from your saved application to protect your privacy. You will need to re-enter this information before submitting your application