Paris Junior College-EOC

INTAKE APPLICATION

Please complete the application below so we can determine your eligibility for TRIO Educational Opportunity Centers (EOC) program services at Paris Junior College.

For any questions or assistance, email trioeoc@parisjc.edu or call 903-782-0353.
Social Security Number*
999-99-9999
Name*

First NameMILast Name
Where did you hear about EOC?
E-mail Address*
example@example.com
Telephone Number*
(999)999-9999
Address (Number and Street include Apt. Number) NO P.O. Box*

Street Address

Street Address Line 2

CityState

Zip code
In what county do you currently reside?*
Other county, if applicable
Date of Birth*

MonthDayYear
mm-dd-yyyy
Current Age*
Gender*

FemaleMale
Are you a U.S. Citizen?*

YesNo
If no, are you a legal resident?*

YesNo
PRC#*
What is your race? (check all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic/Latino of any raceWhiteNative Hawaiian or other Pacific Islander
Are you Hispanic/Latino?*

YesNo
What is your current marital status?*

SingleMarriedDivorcedSeparated
What is your employment status?*

Full-TimePart-TimeUnemployed
Do you receive any of the following income source(s): (mark all that apply)

Welfare (TANF)Food Stamps (EBT)Social Security (SSI)Unemployment BenefitsVeteran BenefitsOther
Current Education Status: (Please check your current educational status. Please check only one.)*

High School Non-Senior (grades 9,10, or 11)High School SeniorHigh School Drop outHigh School GraduateEarned GEDCollege StudentCollege Drop outPost-secondary Certificate Earned (1 Year)College Graduate
High School Non-Senior (grades 9,10, or 11) - High School
High School Non-Senior (grades 9,10, or 11) - Grade
High School Senior - High School
High School Senior - Class of:
High School Drop out - High School:
High School Drop out - Check as many as apply:

Dropped out in 9th GradeDropped out in 10th GradeDropped out in 11th GradeDropped out in 12th GradeNot enrolled in an Alternative Education/GEDEnrolled in an Alternative Education/GED Program - Program Name:
High School Graduate- High School:
High School Graduate- Year Graduated
Earned GED - Year Earned:
Earned GED - Program Name:
College Student - Currently enrolled at:
College Student ID #:
College Student - Major:
College Student - Are you interested in transferring to a 4 - year university?

YesNo
College Drop out - Last College attended:
College Drop out - Semester/Year
Post-secondary Certificate Earned (1 Year) - Year Earned:
Post-secondary Certificate Earned (1 Year) - College:
College Graduate - College/University Name:
College Graduate - Degree(s) Obtained:

Associate Degree (2 year)Bachelor's Degree (4 year)Other
College Graduate - Year Earned:
College Admissions Application Status:*

I have completed a college admission applicationI have not applied yetNot Applicable
I have completed a college admission application to...
Student Financial Aid Application*

I have completed a FAFSAI have not applied yetNot applicable
Which school year did you complete?
Last year, what was your family's "TAXABLE" income?* Taxable income is your gross income, minus any exemptions or deductions. Your 2022 taxable income can be found on IRS form 1040, line 11b.*
Did you receive a High School Diploma?*

YesNo
Did you receive a GED?*

YesNo
From where did you get your diploma/GED? (list school name, city & state)*
Year HS/GED Received?*
Are you currently a senior in a High School Diploma program?*

YesNo
Are you currently working on getting your GED?*

YesNo
What school/program are you currently attending to get your diploma/GED?*
In what grade did you drop out of high school?*
Do you have the desire to pursue an education beyond high school?*

YesNo
Are you currently attending college or a vocational training program?*

YesNo
Where do you currently attend college? (institution, city & state)
Have you ever attended college or a vocational training program?*

YesNo
Where did you last attend college or a training program? (list school name, city & state)*
When did you last attend college? (year only)*
Do you have a college degree?*

Associate of Arts or Science Degree (AA/AS)Bachelor of Arts or Science Degree (BA/BS)I do not have a college degree
Military- Connected (Check any that apply)*

Not ApplicableVeteranSpouse of Active Duty MilitaryActive Duty MilitaryChild of Active Duty MilitaryChild of a Veteran
Will you be applying for VA benefits?

YesNo
Is anyone in your family a Veteran of the U.S. Armed Forces? (mark all that apply)*

SelfSpouseParent/GuardianNone of the above
Is anyone in your family active-duty military? (mark all that apply)*

SelfSpouseParent/GuardianNone of the above
Mark all that apply

HomelessEx-offenderDisabledActive-duty militaryFormally in Foster Care Ward of Court
What services are you interested in receiving? (check all that apply)*

Academic/Career GuidanceAdmissions/College ApplicationsFinancial Aid Applications/FAFSATesting/GED AssistanceFinancial Literacy/Budget PlanningCollege Transfer AssistanceTutoring/Study SkillsOther
Have you ever participated in any of the following TRIO programs? (check all that apply)*

Educational Opportunity CentersUpward Bound/Math & ScienceEducational Talent SearchVeteran's Upward BoundGear UpMcNairStudent Support ServicesNone of the above
Do you have the desire to pursue an education beyond high school?*

YesNo
Where do you plan to attend college?*

Paris Junior College - Paris CampusParis Junior College - Greenville CenterParis Junior College - Sulphur Springs CenterNortheast Texas Community CollegeEast Texas A&M UniversityUndecidedInterested in a GEDOther College/University
When do you plan to enroll in college or a GED program?*

Fall (August - December)Spring (January - May)Summer I or II (June/July)Other
EOC helps you plan your educational future. Which of the following services would be helpful to you? (Check all that apply)
Financial Aid Assistance*

Free Application for Federal Student Aid (FAFSA)Student Loan ApplicationStudent Loan DefaultScholarship AssistanceFAFSA VerificationBudgeting for CollegeTesting Fee Waiver (TSIA2/GED)Other
College Admissions Assistance*

Admissions ApplicationApplication Fee WaiverCollege SearchTransfer AdvisingCollege Re-entryOther
Other*

Academic PlanningCareer AdvisingGED/TxCHSEEmployability SkillsTutoring/Study SkillsJob Interviewing SkillsResume WritingOther
Did either parent (natural or adoptive) with whom you regularly resided with and received support from, graduate from a 4-year college, prior to your 18th birthday?*

Parent 1 (mother)Parent 2 (father)BothNeither
Dependency Status: (Please check all that apply to you)*

As of Today, you are at least 24 years oldCurrently Married or SeparatedHave children or have other dependents who receive more than 1/2 of their support from youUS Armed Forces veteran or on active dutyIn foster care, ward of the court, or both parents deceasedEmancipated minor or in a legal guardianshipUnaccompanied/Homeless YouthHave completed a 4-year college degree and working on master's or doctorate degreeNone of these options apply to me - Dependent Student
Did ANY of the above Dependency Status criteria apply to you?*

Yes = You are an Independent StudentNo = You are a Dependent Student
On your most recent tax return, what was your family's TAXABLE income? On the IRS form 1040, this amount can be found on line 15. If you did not file a tax return, enter "0". *
Number of Family Members in Your Household*
Includes yourself, your spouse, your children, and any other individual who is receiving more than half of their support from you.
Income Statement - On your most recent tax return, what was your family's TAXABLE income? On the IRS Form 1040, this amount can be found on line 15. If you did not file a tax return, enter "0". *Please note that TAXABLE income is usually much lower than adjusted gross income because it accounts for deductions and tax breaks, reducing the portion of earnings subject to federal tax*
Your Household's Annual TAXABLE Income
Participants may need to meet financial eligibility criteria to be admitted to the EOC program. Please provide a phone number and email address for your parent/guardian. They will receive notification that you have applied to the TRIO Educational Opportunity Centers program at Paris Junior College and will be asked to complete an income verification form so that we can review your eligibly. This form must be completed by a parent/guardian to complete your application.
Parent/Guardian First and Last Name*

First NameLast Name
Parent/Guardian Phone Number*
(999)999-9999
Parent/Guardian Email Address*
example@example.com
Number of Family Members in Your Household
Includes your parents, yourself, your parents' other children, and any other individual who is receiving more than half of their support from your parents
Income Statement - On your most recent tax return, what was your family's TAXABLE income? On the IRS Form 1040, this amount can be found on line 15. If you did not file a tax return, enter "0". *Please note that TAXABLE income is usually much lower than adjusted gross income because it accounts for deductions and tax breaks, reducing the portion of earnings subject to federal tax.
Parent(s) Taxable Income

Number in Family (include self)*

	Adults	Children
Number in Family (current household) include self

Signature

Clear
Income Verification Section

In order to satisfy the Department of Education requirements to document family income, I certify that the following is true and correct to the best of my knowledge:
Did you file a federal a 2023 or most recent 2024 income tax return (1040/1040A/1040EZ)?*

YesNo – but did have a source of incomeNo – I am considered INDEPENDENT and not required to file an income tax returnNo – I am considered DEPENDENT and my parent(s) is not required to file an income tax return
My filing status was:*

SingleHead of HouseholdMarried Filing JointlyMarried Filing SeparateQualifying Widow(er) with dependent child
The Adjusted Gross Income (AGI) was: *
The source(s) of income for 2020 or 2021 were (check all that apply):*

Wages from employment in the amount ofSSI/Other Social Security Benefits in the amount ofChild Support in the amount ofOther Source(s) in the amount of
Wages from employment in the amount of $:*
SSI/Other Social Security Benefits in the amount of $:*
Child Support in the amount of $:*
Other Source(s) in the amount of $:*
Signature

Clear
Electronic Signature: I declare under penalty of perjury that the information on this form is true to the best of my knowledge.

Information Release: Pursuant to 20 USA 1231a of the U.S. Department of Education, PJCEOC is authorized to access information deemed necessary to assist me in achieving my educational goals or in meeting the reported requirements of the U.S. Department of Education, to record pertinent facts regarding my eligibility in the program, services rendered, and post-secondary education enrollment. This information is protected by the Privacy Act, kept confidential and not be seen unless specifically authorized. A copy of this statement shall serve as such authorization. I allow personnel to conduct and communicate information pertaining to my educational outcomes as they relate to the EOC project using phone, email, text messaging or other digital mediums.

For dependent students, EOC requires a parent/guardian signature to authorize the information on this application. An EOC staff member will assist you with this when appropriate.
Consent:*

I certify that all information provided on this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may affect my eligibility for the TRIO Educational Opportunity Centers (EOC) program. I authorize EOC to access my educational records for the purpose of determining my eligibility and providing services. This includes, but is not limited to, my grades, test scores, enrollment status, high school and college transcripts, and student financial aid records. Additionally, I consent to the release of information from my participant file to state and federal agencies as required by law or program regulations. By checking this box, I acknowledge that I have read and understand this consent statement.
I would like to receive text message regarding my appointments, deadlines, scholarships, and other necessary communication.*

YesNo
Best Phone Number
(999)999-9999
Signature of Applicant*

Clear
Today's Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature (required if you are considered a Dependent Student)

Clear
Dependent Student: A Student who does not meet any of the criteria for an independent student. An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.
Today's Date

MonthDayYear
mm-dd-yyyy
TRIO Educational Opportunity Centers (EOC) at Paris Junior College is 100% federally funded by the U.S. Department of Education. TRIO EOC serves 1,100 participants annually who are from low-income backgrounds, first-generation college students and/or participants with disabling conditions, with a budget of $383,770. Paris Junior College prohibits discrimination, including harassment, against any student on the basis of sex or gender, race, color, national origin, disability, religion, age, or any other basis prohibited by law. A lack of English language skills will not be a barrier to admission and participation in the career and technical education programs of PJC.