EOC Application

DEMOGRAPHIC INFORMATION

How did you hear about us?*

Name*

First Middle Last

Birthdate*

Gender*

Race/Ethnicity*

Citizenship*

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Preferred Contact Method(s)*

Telephone (Home/Cell)*

Please enter 000-000-0000 if you do not have a phone.

Email*

ACADEMIC INFORMATION

Current Education Level*

Grade*

College Name*

Do you have difficulty in speaking English?

Yes
No

Military Connected Individuals: If applicable, please select one of the following

Did either parent graduate from a four - year college?*

Yes
No

Are you currently being served by another TRIO program?*

Educational Goal(s): Please list any educational goals or careers that you are interested in pursuing.

What College(s) or Vocational/Trade School(s) are you considering?*

Please check one box to verify income*

a signed statement from the individual (if dependent) or the individual’s parent/guardian, verification from another governmental source, a signed financial aid application, or a signed US or Puerto Rico income tax return (IRS Tax Form 1040 Line 43, 1040A Line 27, 1040EZ line 6). In accordance with section 725 of the McKinney - Vento Homeless Assistance Act, individuals who are foster care youth (including youth in foster care and youth who have left foster care after reaching age 13), or homeless children and youths' are excluded from this requirement.

Number of family members supported by that income: (including yourself)*

Please enter a value between 1 and 12.

I would like assistance with the following (Check all that apply)*

GED Information
College/Univ./Trade/Vocational School Admissions
Financial Aid/FAFSA
Career Information
Locating a college or vocational school
Scholarships
Other

Please write down the details

REGULATIONS

Photo/Media Release : ( Parental s ignature r equired if under the age of 18 )

Much of our publication and marketing success is from the use of photos and videos taken of EOC participants during program events. Unless you choose to “Opt Out” of this release, by signing below, you also give the irrevocable right for the EOC program to use your name, photo, or video in all forms and media and in all manners, including composite or distorted representations, for advertising, trade or any other lawful purposes, and you waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith.

OPT OUT

Text Message Release: ( Parental signature required if under the age of 18 )

Unless you choose to “Opt Out” of this release, the EOC program would like utilize text/SMS messaging services to alert you of important timelines, events, and scholarships/FAFSA deadlines until such time as I notify the EOC program to discontinue this service.

OPT OUT

FERPA Certi fication and Release:

The Family Educational Rights and Privacy Act or FERPA, was enacted to protect the privacy of student records. By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of the my official academic records to the Educational Opportunity Center (EOC), understanding that the information in these records will be used only to assess the need for program services, to evaluate the effectiveness of program activities, and to fulfill program-reporting requirements until such time as I revoke this release by notifying the EOC program in writing. Furthermore, I hereby give the EOC permission to forward my information to other programs and or departments whose services will best meet my needs.

Applicant Signature*

Press and hold the left mouse button in the box and draw your signature.
If you want to delete it and try again simply press "Clear" icon in the bottom right corner.

Date*

Parent/Guardian Signature required if under the age of 18

Press and hold the left mouse button in the box and draw your signature.
If you want to delete it and try again simply press "Clear" icon in the bottom right corner.

Date

Please type the words or numbers in the box. If you want to delete it and try again simply press "Clear" icon in the top right.