Gadsden State Community College-EOC-Application Form

CHEAHA EDUCATIONAL OPPORTUNITY CENTER (EOC)
APPLICATION
GADSDEN STATE COMMUNITY COLLEGE
Name:*

First NameMiddleLast Name
Date of Birth:

MonthDayYear
mm-dd-yyyy
Gender:

MaleFemale
Email address:*
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity:
Native Language:
Are you a U.S. Citizen?

YesNo
Are you a Veteran?

YesNo
Status:

SingleMarriedDivorced
Mobile Number:
(999)999-9999
Can we communicate with you via text?

YesNo
Are you a part of any of the following federal programs?

TRIO Talent SearchEOCUpward Bound
Are you a resident of Calhoun, Cleburne, Cherokee or Etowah County?

YesNo
Are you 19 years of age or older?

YesNo
Are you a high school senior?

YesNo
Are you currently enrolled in high school or college?

YesNo
Do you have a GED or high school diploma?

YesNo
Are you a first-generation college student? (You are considered a first-generation college student if neither of your parents have a four-year college degree)

YesNo
Are you a dependent?

YesNo
Annual household income?
Number of people (including you) in your family household? (You are NOT a dependent if you are 24 years of age or older, married, or a parent.)
How did you hear about us?
Please check ALL the services you need:

Admission/Application AssistanceCareer Counseling/Major SelectionTutorial Information/AssistanceFinancial Aid Application Assistance (FAFSA)Scholarship Research AssistanceCollege Entry Testing InformationBudgeting & Personal Financial PlanningESL/TOEFL PreparationInformation on GED Classes & TestingDegree & Program InformationOther
Phone: Home
(999)999-9999
Check All That Apply:

CallTextEmail
Race:

American Indian/Alaskan NativeAsianBlack/African AmericanWhiteNative Hawaiian or IslanderMore than one race (Please mark all that apply.)
Are you of Hispanic ethnicity?

YesNo
Is English your native language?

YesNo
If you are not a U.S. Citizen, are you a permanent resident?

YesNo
Green Card #
Are you currently a participant in a Talent Search or EOC program?

YesNo
Did either of your parents/legal guardians graduate from a 4-year university?

YesNo
If YES, please list the university name:
Disability Eligibility:
Do you have a disability?

YesNo
If yes, please list disability:
Accommodations requested:
Academic Goals:
Academic Goals:

GED CompletionRefresher SkillsCollege EnrollmentOther (Please specify):
I verify that the information on this form is true and complete to the best of my knowledge and grant the Cheaha Educational Opportunity Center (EOC) staff permission to review information maintained as part of my permanent records, including admissions data, enrollment data, or other information pertinent to my status in the EOC Program. I authorize EOC to obtain information from financial aid including financial awards. I give Gadsden State permission to send my information to the National Student Clearinghouse for future tracking of college enrollment and/or graduation. I understand my photo may be taken at EOC events and used on marketing and social media. Choosing to opt out of photo opportunities during these events will be my own responsibility. Failure to remain an active EOC participant will result in removal from the program
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Independent Student:
Check which was your taxable income in 2021:

Below $19,320$19,320 --- $26,129$26,130 --- $32,939$32,940 --- $39,749$39,750 --- $46,559$46,560 --- $53,369$53,370 --- $60,179$60,180 --- $66,989$66,990--$73,799$73,800--$80,609$80,610 or more
Dependent Student:
Number in household
Check which was your taxable income in 2021:

Below $19,320$19,320 --- $26,129$26,130 --- $32,939$32,940 --- $39,749$39,750 --- $46,559$46,560 --- $53,369$53,370 --- $60,179$60,180 --- $66,989$66,990--$73,799$73,800--$80,609$80,610 or more
Workshops:

Improving Computer SkillsStress ManagementStudy SkillsTest TakingTime ManagementTransfer PlanningUnderstanding Financial Aid
It is the policy of the Alabama Community College System, including all institutions under its control, that no person shall, on the grounds of race, color, disability, gender, religion, creed, national origin, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or employment. (Each institution will make reasonable accommodations for qualified disabled applicants or employees.)
Cheaha Educational Opportunity Center is fully funded by a grant of $232,050 by the U.S. Department of Education
Dependent Students and Independent Students
If you can answer “yes” to any of the questions below, please check the box.
A student can be considered an Independent Student (even if a student is under the age of 24) for the following reasons:

Were you born before January 1, 1998?As of today, are you married?Are you currently serving on active duty in the U.S. Armed Forces for purposes other than training?Are you a veteran of the U.S. Armed Forces?Do you now have, or will you have, children who will receive more than half of their support from you between July 1, 2021 and June 30, 2022?Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their support from you, now and through June 30, 2022?At any time since you turned age 13, were both your parents deceased, were you in foster care or were you a dependent or ward of the court?*As determined by a court in your state of legal residence, are you or were you an emancipated minor?Does someone other than your parent or stepparent have legal guardianship of you, as determined by a court in your state of legal residence?At any time on or after July 1, 2021, did your high school or school district homeless liaison determine that you were an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?At any time on or after July 1, 2021, did the director of an emergency shelter or transitional housing program funded by the U.S. Department of Housing and Urban Development determine that you were an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?At any time on or after July 1, 2021, did the director of a runaway or homeless youth basic center or transitional living program determine that you were an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?
* If you are not sure if you were in foster care, check with your state child welfare
agency. You can find out the contact information for your state child welfare
agency by visiting your state child welfare agency.
Number in my household
My household taxable income for 2021 was
$
I file as

IndependentDependent
GADSDEN STATE COMMUNITY COLLEGE
CHEAHA EDUCATIONAL OPPORTUNITY CENTER (EOC)
INCOME VERIFICATION FORM

I, {main_name}, as an applicant for the Educational Opportunity Center (EOC) Program at Gadsden State Community College (GSCC) do hereby verify, to the best of my knowledge, that my household taxable income for 2021 was ${myHousehold}.

Number in Family {numberIn85}. {iFile}
Parent’s Signature (Dependent Student Only)

Clear
Student’s Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
EDUCATIONAL OPPORTUNITY CENTER (EOC)

Confidentiality Statement

The EOC Program Staff and tutors are here to help you be successful at earning your GED or diploma, or enrolling in college. While we pride ourselves on being an active and cooperative learning community, we also understand the importance of protecting the confidentiality of the academic and personal information you share with us.

This statement is to notify all EOC participants that academic and personal confidentiality can be breeched when GSCC policy mandates that security, administrators or staff be notified. In order to maintain a productive and safe environment for everyone, please read and sign the Student Code of Discipline standards related to mandatory staff reporting.

Student Code of Conduct (Actions requiring mandatory reporting):
1. Destruction, damage, theft or misuse of College public or private property
2. Being in possession of or under the influence of alcoholic beverages or non-prescribed, controlled drugs on College property or at a student or College-sponsored function
3. Disruptive or disorderly conduct that interferes with or threatens the health and/or safety of the College community or adversely affects the educational environment of the College including physical or verbal abuse, threat of violence, intimidation, and physical or mental harassment
If you tell an EOC staff member or a tutor that you are in immediate danger of hurting yourself or someone else, we are obligated to inform GSCC Administrators.
Student Name (Print):

First NameLast Name
Date:

MonthDayYear
mm-dd-yyyy
Student Name (Signature):

Clear

Dependent Students and Independent StudentsIf you can answer “yes” to any of the questions below, please check the box.

GADSDEN STATE COMMUNITY COLLEGECHEAHA EDUCATIONAL OPPORTUNITY CENTER (EOC)INCOME VERIFICATION FORM

EDUCATIONAL OPPORTUNITY CENTER (EOC)

Dependent Students and Independent Students
If you can answer “yes” to any of the questions below, please check the box.

GADSDEN STATE COMMUNITY COLLEGE
CHEAHA EDUCATIONAL OPPORTUNITY CENTER (EOC)
INCOME VERIFICATION FORM