TRIO EOC / University of Central Oklahoma-EOC

Personal Information
Name*

First NameLast Name
Gender*

FemaleMale
Phone *
(999)999-9999
Email*
example@example.com
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
999-99-9999
Date of Birth *

MonthDayYear
mm-dd-yyyy
Race / Ethnicity: (Check all that apply)*

American Indian/Alaskan NativeNative Hawaiian/Pacific IslanderAsianBlackHispanic/LatinoWhite

Educational Background
Do you have your high school diploma or GED?*

YesNo
Are you enrolled in high school or a GED program?*

YesNo
Name of High School/GED Program *
High School Grade Level *
Have you ever attended a college / technology center?*

YesNo
Name of College/Technology Center *
Do you have an associate’s degree or certificate?*

YesNo
Have you ever participated in any of the following TRIO programs?*

GEAR UPStudent Support ServicesTalent SearchUpward BoundUpward Bound Math and ScienceVeterans Upward BoundNO TRIO Background
What is your career interest?*
Why is obtaining a college degree important to you?*
What are your short-term goals?*
What are your short-term goals?*

GED/HiSET CompletionApply for College/Career TechApply for Financial Aid/ScholarshipsGet a JobOther
What are your long-term goals?*
What are your long-term goals?*

Apply for College/Career TechEnroll in College/Career TechObtain a Degree/CertificationApply for Financial Aid/ScholarshipsOther
Directions: Read each item carefully. Using the scale shown below, please select the number that best describes YOU and put that number in the blank provided.

1. = Definitely False 2. = Mostly False 3. = Somewhat False 4. = Slightly False
5. = Slightly True 6. = Somewhat True 7. = Mostly True 8. = Definitely True

Please select the number that best describes YOU*

	Rating 1-8
1. I can think of many ways to get out of a jam.
2. I energetically pursue my goals.
3. I feel tired most of the time.
4. There are lots of ways around any problem.
5. I am easily downed in an argument.
6. I can think of many ways to get the things in life that are important to me.
7. I worry about my health.
8. Even when others get discouraged, I know I can find a way to solve the problem.
9. My past experiences have prepared me well for my future.
10. I’ve been pretty successful in life.
11. I usually find myself worrying about something.
12. I meet the goals that I set for myself

I verify that the information that I provided is correct and give permission for the UCO CARES program to use this information to determine my eligibility for program services. I give permission for the release of my official academic records and financial aid information to the UCO CARES staff to be used in needs assessments, program planning, and reporting purposes. I fully intend to enroll in a technology center or college.
Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy