Gifted Programs: You will receive information on opportunities for academically talented students. Would you also like to receive information from select private schools on their qualifying criteria and scholarship opportunities?

Yes NoCenter for Talent Development only endorses

programs it administers.

Parent/Guardian #2 First Name MI Parent/Guardian #2 Last Name

Phone (area code first) E-mail Address

Street Address

City State ZIP

Student First Name (First 18 letters) MI Student Last Name (First 18 letters) Gender M F

School Information: Homeschooled OR Enter your school’s NUMATS ID number: ___ ___ ___ ___ ___ ___ ___ , if known, OR School Name: _________________________________________________________________________School Address: ___________________________________ City, State, ZIP: _______________________

Qualifying Information (Check all that apply.) I am a past participant in an Academic Talent Search. I qualify for the gifted program at my school. I have been recommended by a teacher or parent. I qualify on a nationally normed test. I qualify on a state achievement test.

Parent/Guardian #1 First Name MI Parent/Guardian #1 Last Name

2016 Northwestern University’s Midwest Academic Talent Search (NUMATS)

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1Current Grade Level

3 4 5 6 7 8 9 ( )

MM / DD / YYYY Date of BirthEthnic Background (optional)

African-American/Black Asian/Pacific Islander Caucasian/White Hispanic/Latino Native Alaskan/American Indian Multiracial Other ____________________ For statistical purposes only

Household Income(optional)

Under $20,000 $20,000-$49,999 $50,000-$79,999 $80,000-$119,999 $120,000 or above

Phone (area code first) E-mail Address (This e-mail address will be your username for your online Toolbox account.)

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Additional Score Reports: If you would like the testing agency to send your scores to up to two other institutions, enter the institution code(s): ____ ____ ____ ____ ____ ____ ____ ____

See Box 9

Participation Agreement (required):• I understand the requirements for participation in NUMATS and verify that my child meets all these requirements; I agree to the conditions of my child’s participation in NUMATS; and I give permission for myichild to participate in NUMATS.• I understand that fees are not refundable for any reason and may not be transferred to registration in future years.• I understand I will be charged $30 for each returned check.• I understand that if the test centers I requested are not available, the testing agency will assign me to the nearest available test center.• I understand that if I change the test date, I may be charged a fee by the testing agency.• I understand that my child’s test scores will be available to the school or school district I identified.• I understand that my child’s scores and contact information may be made available to other agencies/institutions to determine eligibility for award ceremonies, special programs, or scholarship opportunities.• Data Collection & Research: By participating in a CTD program, we understand that any data we supply with the application or that is generated as a result of participation in the program is collected in CTD’s idatabases, which are stored on a secure server maintained by Northwestern University staff only, and that aggregated and de-identified information may be used for program evaluation, quality assessment, istrategic planning, and research purposes. CTD will maintain appropriate safeguards to protect the security, integrity, and privacy of students’ personal data.• I understand that information available to me on MyCTD Toolbox or Schoology is proprietary in nature, and I agree to only share it with others in the CTD community.

For ACT registrants only (student must sign and date):I certify that I am the person whose name and signature appear on this form and that the information provided is accurate to the best of my knowledge. I agree to comply with and be bound by ACT’s Terms and Conditions set forth in the 2015-2016 ACT Talent Search Instructions and listed at www.actstudent.org/regist/terms.html, including those concerning test security, score cancellation, exam-inee remedies, arbitration, and ACT’s Privacy Policy available at http://www.act.org/privacy.html.

______________________________________________ _____/_____/_____Student Signature Month/Day/Year

For SAT registrants only (parent must read and check box):☐ I have read and understand the information in NUMATS’ Family Handbook 2016 avail-able at www.ctd.northwestern.edu/sites/default/files/NUMATS_Family_Handbook.pdf as well as SAT’s test-related guidelines in SAT Registration Rights & Responsibilities of the Student available at www.ctd.northwestern.edu/sites/default/files/SAT_Registration_Rights_Responsibilities.pdf and give permission for my child to enroll in this academic talent search program.

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Financial Aid: NUMATS and test fee waivers are available on a limited first-come, first-served basis for one registra-tion per school year to students who qualify (see Family Handbook 2016). An eligibility letter stating that the student qualifies, written on school letterhead and signed by a school official, is required and should be submitted to NUMATS with this form. We must receive the letter by the registration deadline to process registration for your chosen test date. Registration is not complete until NUMATS receives this letter. If unable to provide this letter, contact NUMATS for other options.

Students requesting financial aid and registering for ACT or SAT do not need to submit payment with this form. Use Box 11-1, Line D and Box 11-2, Line K. (Students in grade 7 who qualify for financial aid will receive a JKC test fee waiver and should use Box 11-2, Line L.) Students requesting financial aid and registering for EXPLORE must include payment for the test fee. Use Box 11-1, Line D and Box 11-2, Line E or F.

ACT and EXPLORE registrations received during late registration periods must include late fee payments. Use Box 11-2, Line M (ACT) or Line F (EXPLORE).

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.Special Accommodations: Each testing agency determines allowable accommodations and has its own application process. (See Family Handbook 2016.) Required forms and instructions will be sent to you upon receipt of this completed form. Check here if requesting special accommodations.

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For All Tests (parent must sign and date):______________________________________________________________ _____/_____/_____ Parent Signature Month/Day/Year

There’s a much easier way! Register online at my.ctd.northwestern.edu. Questions? Call 847/491-3782 ext. 3.

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*SAT now requires all 9th graders to register for the test directly through their website: sat.collegeboard.org/register. After registering, request a score report be sent to us by searching Colleges and Scholarships in Evanston, IL and choosing NORTHWESTERN UNIVERSITYS MIDWEST ACDMC TALENT SRCH to ensure you have access to all NUMATS benefits. On this form, use Box 11-1, Line C and Box 11-2, Line N.

EXPLORE: Offered to students in grades 3-6. Indicate a first- and second- choice test date and test center. For a test center lookup, go to www.ctd.northwestern.edu/numats-test-centers, contact the NUMATS coordinator at your school, or call NUMATS at 847/491-3782 ext. 3.

Credit Card Select one: MasterCard Visa Discover JCB Diner’s Club

Card number: Exp: / Billing ZIP Code:

Signature: __________________________________________________________________ Date:_____________ Amount: $________

Please enclose check or money order for the Grand Total amount made payable to Northwestern University or complete credit card information in Box 13. Mail registration and payment to arrive by the deadline for the earliest test you selected to

NUMATSCenter for Talent Development

617 Dartmouth PlaceEvanston, IL 60208

Indicate payment method: Check (enclosed) Money Order (enclosed) Credit/Debit card (Complete Box 13.)

Register for more than one test on the same form! Consider taking each test applicable to your current grade level. Testing before March is required for award ceremony consideration by some state organizations.

We must receive your registration and all accompanying paperwork by the registration deadline to process registration for your chosen test date.

Test Information Fees: Mark all that apply.

Test Date° Deadline Late Period (+$25 late fee) Test CentersSep 12 Aug 5 Aug 6-18

1st Choice:____ ____ ____ ____ ____ ____Oct 24 Sep 16 Sep 17-29

Dec 12 Nov 4 Nov 5-17Feb 6 Jan 6 Jan 7-12

2nd Choice: ____ ____ ____ ____ ____ ____Apr 9 Mar 2 Mar 3-15

Jun 11 May 4 May 5-17

Test Date Deadline Late Period (+$14 late fee)Nov 7 Oct 7 Oct 8-13Jan 23 Dec 16 Dec 17-29 Jan 24 **Non-Sat. See Box 10. Dec 16 Dec 17-29Feb 20 Jan 13 Jan 14-19

1st Choice: Date (circle one):Nov Jan Feb

Test Center: ____ ____ ____ ____ ____ ____

2nd Choice: Date (circle one):Nov Jan Feb

Test Center: ____ ____ ____ ____ ____ ____

7 N NUMATS Fees:A. EXPLORE $39.00 = ____B. ACT $39.00 = ____C. SAT $39.00 = ____D. Financial Aid $0 = ____ (See Box 4.)

AND Test Fees: E. EXPLORE $35.00 = ____F. EXPLORE w/ late fee $49.00 = ____G. ACT $39.50 = ____H. ACT w/ late fee $64.50 = ____I. SAT without essay $43.00 = ____J. SAT w/ essay   $54.50 = ____K. ACT or SAT w/ Financial Aid $0 = ____L. JKC Fee Waiver (See Box 4.) $0 = ____M. ACT late fee only $25.00 = ____N. SAT 9th grader $0 = ____

Total of 11-1 and 11-2 = $ _____ Optional: Imagine magazine is the only magazine written just for gifted students in grades 7-12. (See Family Handbook for more information.) Imagine subscription $30.00 = _____ (1 year - 5 issues)

Grand Total: $ ________

11-1

11-2

ACT: Offered to students in grades 6-9. Choose one test date, then enter first- and second-choice test centers. For a test center lookup, go to www.ctd.northwestern.edu/numats-test-centers, contact the NUMATS coordinator at your school, or call NUMATS at 847/491-3782 ext. 3.

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   SAT: Offered to students in grades 6-9. Choose one test date, then enter first- and second-choice test centers. For a test center lookup, go to www.ctd.northwestern.edu/numats-test-centers, contact the NUMATS coordinator at your school, or call NUMATS at 847/491-3782 ext. 3.

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Test Date Non-Sat Test Date** Deadline Test CentersSAT Current (with essay) 1st Choice:

____ ____ ____ ____ ____Oct 3 Oct 4 Aug 31Nov 7 Nov 8 Oct 6 2nd Choice:

____ ____ ____ ____ ____Dec 5 Dec 6 Nov 2Jan 23 Jan 24 Jan 4

*9th graders must alsoregister directly with SAT and

have a photo ID.

SAT Redesigned (with or without essay)Mar 5 Mar 6 Feb 2May 7 May 8 Apr 5Jun 4 Jun 5 May 2

12

13

For office use only CC MO Ck Ck/MO/CC $_______ Ck/MO #__________ Pymt proc’d on ______ by _____ JKC Allowed ReleaseReg rec’d ________ by ______ School Pymt Bulk Paper Indiv Paper MATS FW Non-SatChecked on ______ by ______ SP Ck # ___________ SP approved/applied in WB on __________ by _____ Test FW Spec Acc Entered in WB on _______ by ______ E-mail conf sent on _______ by ______ Spec Acc sent on _______ by _____ No Sig NUMATS Only

**Non-Saturday Testing: Students whose religious faith prohibits Saturday testing may choose a non-Saturday test date. Students must include a letter from their clergy requesting this option with this registration form. (See Family Handbook 2016 for more information.) Additional dates may be available in your state. Call us at 847/491-3782 ext. 3 for more information. Check here if you are choosing a non-Saturday test date for religious reasons, and indicate your preferred test date in Box 7, 8, or 9.

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** °ACT Non-Saturday test dates vary by state. Check ACT’s website for dates and test centers, and enter the test date here.___________________________________