Miami Dade College-EOC

627 SW 27th Avenue, Room 1111 Miami, FL 33135
Office: 305-237-6488 • Email: trioeocmiami@mdc.edu

The Educational Opportunity Center of Miami Dade College is a federally funded TRIO program with the mission of providing FREE secondary and postsecondary information and assistance to eligible adults in Miami-Dade County. To participate, please complete this application.

PARTICIPANT APPLICATION INFORMATION
Name*

First NameLast Name
Birth Date*

MonthDayYear
mm-dd-yyyy
Gender
Gender

FemaleMaleNonbinary or another gender
Address*

Street Address

Street Address Line 2

CityState

Zip
Mobile Phone*
(999)999-9999
May we send text messages to the mobile number provided?*

YesNo
Email*
example@example.com
Social Security Number
999-99-9999
If Dependent, Parent Contact Name:*

First NameLast Name
Phone*
(999)999-9999
Relationship*
Native Language:

EnglishSpanishCreoleOther
Are you receiving services from a federally funded TRIO program?

YesNo
Race and Ethnicity
Hispanic/Latino

YesNo
Race and Ethnicity

Hispanic/Latino of any raceBlack or African American, non-Hispanic/LatinoWhite, non-Hispanic/LatinoAmerican Indian or Alaska Native, non-Hispanic/LatinoAsian, non-Hispanic/LatinoNative Hawaiian or Other Pacific Islander, non-Hispanic/LatinoTwo or more races, non-Hispanic/LatinoOther
Veteran/Military-Connected Students
Are you veteran or military-connected?*

YesNo
Are you a veteran?*

YesNo
Are you an active-duty military?*

YesNo
Are you a spouse of an active-duty military?*

YesNo
Are you a child of an active duty military?*

YesNo
Are you a U.S. Citizen?*

YesNo
Are you a permanent resident?*

YesNo
Resident Alien Number*
Copy of your permanent resident card.

Browse Files

Cancelof
If you are not a u.s. citizen or permanent resident, are you in the u.s. for other than a temporary purpose? (if yes, you must provide evidence from uscis.)*

YesNo
Evidence from USCIS*

Browse Files

Cancelof
Do you have a 4 or 5-year university degree (completed bachelor’s degree)?*

YesNo
Does your mother or father have a 4 or 5-year University degree (completed bachelor’s degree)?*

YesNo
Taxable Annual household income is less than or equal to*

$23,475$31,725$39,975$48,225$56,475$64,725$72,975$81,225Other
Select the number of people supported by that income (household size including yourself)*

12345678Other
Other sources of income:

Supplemental NutritionAssistance program (SNAP)Temporary Assistance (TANF)Supplemental Security Income (SSI)Child SupportHousing (Section 8)Other
As of today, what is your grade standing?*

12th Grade , High School SeniorHigh School Graduate or GED GraduateIncomplete High School or Incomplete GEDCurrent College/University StudentIncomplete CollegePotential College Transfer
As of today, what is your level of education?*

I graduated from High School or completed a GEDI am currently a High School Senior in 12th GradeI have NOT completed High School and have NOT completed a GEDI am currently a college or university student enrolled in classesI have completed some college classes, but I am not currently enrolled in classes.I am a college student seeking to transfer to another college or university.I possess a college or university degreeOther
Are you currently enrolled in college, university, or vocational school?*

YesNo
If yes, enter student ID #*
If yes, enter the name of the college, university, or vocational school
Are you interested in attending college, university, or vocational school ?*

YesNo
Where would you like to attend college, university, or technical school?
What do you want to major in?
Have you lived in the state of Florida for one year or longer?*

YesNo
How did you learn about the TRIO Educational Opportunity Center of Miami Dade College?
Please select ALL the services you need:*

Informational WorkshopsEducational InformationAssistance Completing Financial Aid ApplicationsAssistance Completing Admissions Applications (i.e. FL Residency)Career Counseling/AssessmentCollege Entry Testing InformationRegistration AssistanceTutoring Information / AssistanceCollege Transfer InformationGED InformationOther
Marital Status*

SingleMarriedWidow(er)SeparatedDivorced
Select an Advisor

Jacques Fitzgerald LemoineYoneisis BentorahElena SimonSebestyen KovacsNo Preference
How did you learn about the TRIO Educational Opportunity Center of Miami Dade College?

Another studentHigh schoolE-mailSocial mediaWebsiteOther
Authorization*

By clicking "Next" below, I hereby authorize Miami Dade College TRIO Educational Opportunity Center (TRIO EOC) to access and release educational and financial records. The request for access to participant information and records is for the sole purpose of assisting the participant through the process of enrolling into a post-secondary institution. This process may include one or all the following services: sharing of resources to improve financial and economic literacy, counseling on financial aid options, basic financial planning skills, and assistance with federal student aid applications, vocational school applications or college applications. Records may include: all grades, all courses/credits, all class schedules, test scores, graduation information, immigration information, financial information, income tax information, status of postsecondary admission, and status of postsecondary enrollment. The request for release of information is for the purposes of research, recruitment, promotion and reporting as it pertains to program objectives and outcomes. Name of Agency to whom personal identifiable information may be released to: TRIO Educational Opportunity Center (TRIO EOC), Miami Dade College school officials, and the United States Department of Education. Non-personal identifiable information may be disclosed to: National and state TRIO associations, community agencies, donors, researchers, recruitment, and promotional material. This authorization will remain continuously in effect until I with draw this authorization in writing or for a maximum of four years. If the participant is not at least 18 years old, the parent or legal guardian of the participant must sign this release.
Certification*

By clicking "Next" below, I certify that all statements given in this application are true and accurate to the best of my knowledge.
AUTHORIZATION FOR ACCESS AND RELEASE OF RECORDS

This authorization is solely for the release of and access to information by Miami Dade College TRIO Educational Opportunity Center (TRIO EOC) for qualified TRIO EOC participants. It is NOT a power of attorney and does not permit any person or organization to act on behalf of a TRIO EOC participant It is solely intended to permit the access to and release of TRIO EOC participant educational records and financial information.

IMPORTANT NOTES:
- Participant must provide their picture identification along with this form.
- The purpose of this form is to request access to and release of participant information. The request for access to participant information is for the sole purpose of assisting the participant through the process of enrolling into a post-secondary institution.
- The request for release of information is for the purposes of research, recruitment, promotion and reporting as it pertains to program objectives and outcomes.
- If the participant is not at least 18 years old, the parent or legal guardian of the participant must sign this release, upon which, those who have signed will receive a copy of this completed form.
DATE:

MonthDayYear
mm-dd-yyyy
NAME OF PARTICIPANT

First NameMiddle InitialLast Name
PARTICIPANT SOCIAL SECURITY NUMBER:
999-99-9999
Access Consent

Consent for FULL ACCESS to and release of educational and financial records (Full access does not give authority to make changes to the particiant's record).Only academic transcriptConsent for LIMITED ACCESS to and release of Educational and Financial Records (Limited access does not give authority to make changes to the student's records)
Records may include:
- All grades
- All courses/credits
- All class schedules
- Test Scores
- Graduation information
- Immigration information
- Financial information
- Income Tax information
- Status of Post-Secondary Admission
- Status of Post-Secondary Enrollment
The following specific information or records may be access and disseminated:

All gradesAll courses/creditsAll class schedulesTest ScoresGraduation informationImmigration informationFinancial informationIncome Tax informationStatus of Post-Secondary AdmissionStatus of Post-Secondary Enrollment
Access Time Frame

Long Term Use: this authorization will remain continuously in effect until I with draw this authorization in writing or for a maximum of four years.One Time Use: This authorization can be used only once.Limited Use: This authorization is effective date...
This authorization is effective date...

MonthDayYear
mm-dd-yyyy
...and expires date...

MonthDayYear
mm-dd-yyyy
Purpose of authorization for access to information by the TRIO Educational Opportunity Center: The purpose of this request for access to fue participant's educational records and financial information is for fue sole purpose of assisting the participant through the process of enrolling into a post-secondary institution. This process may include one or all of the following services: sharing of resources to improve financial and economic literacy, counseling on financial aid options, basic financial planning skills, and assistance with federal student aid applications, vocational school applications or college applications.

Purpose of authorization to release information by TRIO Educational Opportunity Center: Additionally, the purpose of this request to release educational records and financial information is for the purposes of reporting program objectives academic and outcomes to county, state and federal government agencies, including the United States Department of Education. In addition, records and financial information may be used for. research, sharing of best practices to community agencies or state and national TRIO Associations, recruitment ofmonetazy and non-monetary resources, recruitment of participants and partner organizations. Lastly, non-identifiable educational records and financial information may be used to inform fue greater community about program demographlcs, services provided and outcomes.

Name of Agency to whom personal identifiable information may be released to: TRIO Educational Opportunity Center (TRIO EOC), Miami Dade College school officials and the United States Department of Education.

Non-personal identifiable information may be disclosed to: National and state TRIO associations, community agencies, donors, researchers, recruitment and promotional material.

All statements made here are true to the best of my knowledge.
Name of Agency to whom personal identifiable information may be released to: TRIO Educational Opportunity Center (TRIO BOC), Miami Dade College school officials and the United States Department of Education. Additionally:
Participant/Parent or Guardian’s Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy