University Of Arkansas-Little Rock

Delta Educational Opportunity Center

U.S. Department of Education TRIO Programs
Name*

First NameLast Name
Social Security Number*
999-99-9999
DOB*

MonthDayYear
mm-dd-yyyy
Sex*

MaleFemale
Marital status*

singlemarriedseparateddivorcedwidowed
Address*

Street Address

Street Address Line 2

CityState

Zip
Phone Number*
(999)999-9999
Email*
example@example.com
U.S Citizen*

YesNo
If ‘no’ have you applied for permanent status?*

YesNo
Alien number*
Ethnic Background
Do you consider yourself to be Hispanic or Latinx?*

YesNo
Select one which best describes you:*

American Indian or Alaska NativeAsianBlack/African AmericanWhiteNative Hawaiian or other Pacific Islander
Optional: The U.S. Department of Education actively assists the following persons. Please check the box if you meet either of these criteria:

DisabilityVeteranActive dutyReservistSpouse or dependent of military personnelOther

How did you hear about Delta Education Opportunity Center
How did you hear about us?*

Adult EdAgencyWorkshop/PresentationFriend/RelativeMail/Flyer
Name of referring agency, Adult Ed Program, office or workshop location*

Authorization
I declare that the information on this form is true to the best of my knowledge. The TRIO Delta Educational Opportunity Center Program is authorized to access information deemed necessary to assist me in achieving my educational goals or in meeting the reporting requirements of the U.S. Department of Education, to record pertinent facts regarding my eligibility in the Program, services rendered, and placement. A copy of this statement shall serve as such authorization.
Signature of Applicant*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Parent Signature (if under 18)*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy

TRIO: A Federal Funded Program
The University of Arkansas at Little Rock TRIO Delta Educational Opportunity Center Program is a federally funded TRIO program and all services are provided to program participants free of charge. All individuals who meet the eligibility requirements of this program are provided information regarding financial and academic assistance necessary for them to enter higher education for the first time or to return if they have dropped out.

Program Services Needed
Program Services Needed*

I need to complete my GEDI need to complete my high school diplomaI need assistance to apply to college/career schoolI need assistance applying for financial aid (FAFSA, scholarships, etc.)I need assistance transferring to a four-year universityI need assistance with assessment testing (e.g. ACCUPLACER)

Special Assistance Request?
Special Assistance Request?

Loan Default AssistanceCareer AssessmentSchool or college re-admission assistanceDisability academic support information
Trouble with:*

LearningHearingVisualPhysical

Media Authorization
I, the under signed, authorize the TRIO Delta Educational Opportunity Center Program at the University of Arkansas at Little Rock to use photographs and/or videotape with my image in Educational Opportunity Center publications, promotional media, social media, websites and/or news releases.
Signature of Applicant*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Parent Signature (if under 18)*

Clear
Date *

MonthDayYear
mm-dd-yyyy

Informed Consent Authorization
I _____________________ have read and I understand the provided information and have had the opportunity to ask questions. I understand that my participation is voluntary and that I am under no legal obligations. (type your full name in the field labeled (Blank) below)
(Blank)*
By signing, I give my consent to University of Arkansas at Little Rock TRIO Delta Educational Opportunity Center to submit an admission and a financial aid application to post-secondary education programs on my behalf.
Signature of Applicant*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Parent Signature (if under 18)

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

Delta Educational Opportunity Center