Palm Beach State College-Central-EOC-Application Form

Palm Beach State College

Permission Form to Receive TRiO EOC Services

The TRIO Educational Opportunity Center (EOC) is a federally funded program through the U.S. Department of Education and is sponsored by Palm Beach State College. This document can be completed by any individual who seeks assistance from the Educational Opportunity Center.

EOC participants must be:

(1) A U.S. citizen, national, permanent resident or other eligible noncitizen

(2) A high school senior unable to be served by the Educational Talent Search program, high school dropout, veteran, and/or an adult 19 years or older

(3) Enrolled or interested in enrolling in a college, university, or training program
- PERSONAL INFORMATION
- Full Name
  
  First NameLast Name
- Grade:
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Cell #
  (999)999-9999
- Email Address
  example@example.com
- DOB
  
  MonthDayYear
  mm-dd-yyyy
- Gender
- Gender
  
  Other
- Age
- Grade:
- Are you currently in High School?
- If yes, where?
- Grade:
- I agree to receive educational updates from the EOC through text messages (message and data rates apply). In order to opt out of receiving text messages,
- Are you 19 or older?
- Today's Date
  
  MonthDayYear
  mm-dd-yyyy
- How were you referred to the EOC?
- How were you referred to the EOC?
  
  Other
- Specify Event Name
- Have you previously received services from the EOC?
- Applying to attend a TRIO event? Select all that apply.
- Have you previously received services from the EOC?
- NEEDS ASSESSMENT
  
  Which of the following services are you interested in receiving? Mark all that apply.
- Information about and/or assistance with:
- PARTICIPANT PROFILE
- Are you a US Citizen?
- Social Security Number
  999-99-9999
- Alien Registration Number
- Citizenship Status
- What is your current dependency status?
- Reason for qualifying as status selected above
- Reason for qualifying as INDEPENDENT. Select all that apply
- What is your primary language spoken in your home?
  
  Other
- What is your current status in the military?
- Are you the dependent or spouse of a veteran, reserved, or active service member?
- If Yes, which best describes your current status?
- Are you a member of the military or are you the dependent of a member of the military?
- As of today, what is your marital status?
- Are you homeless or at the risk of becoming homeless?
- What is Your Ethnicity?
- Please Select One or More Races
  
  Other
- EDUCATION
- What is your current educational status?
  
  Other
- Do you receive free and reduced lunch?
- SDPBC Student Number
- High School Attended
- Colleges you are interested in:
- Career, Area or College Major of Interest (Or Undecided)
- FIRST-GENERATION STATUS (please answer BOTH questions)
- 1. Which parent(s) did you regularly reside with and receive at least 50% of more of your financial support from during your childhood (i.e., until you were 18 years old)?
- 2. Did the parent(s) listed above receive a four-year college degree (Bachelor's Degree) in the US?
- PARENT/LEGAL GUARDIAN INFORMATION
  
  If you are a dependent student, your parent is required to provide his/her information and a signature at the end of this form.
- Parent/Legal Guardian Name
  
  First NameLast Name
- Cell #
  (999)999-9999
- Parent Email
  example@example.com
- INCOME VERIFICATION (please fill in BOTH responses)
  
  If you are an independent student, please answer the questions below about yourself. If you are a dependent student, a parent must provide information on household size and income.
- 1. Household Size (including you)
- 1. Household Size (including you)
- 2. Taxable income from 2024 income tax form 1040 Line 10 was
- If you did not file please list wages, salaries, tips, and other non-taxed income
- AUTHORIZATION FOR RELEASE OF INORMATION
- To whom it may concern: I, _____________________ (your name) give my permission to any public school, educational program, and/or postsecondary institution that I have attended or may attend in the future as well as the National Student Clearinghouse to release to the PBSC Educational Opportunity Center, upon their request, all information pertinent to my educational program, including a copy of my financial aid application and awards, transcripts, college enrollment status. I also authorize the use of my name and/or photograph for editorial, promotional, recruitment or educational purposes. By completing and submitting this application, I attest that all of the information on this application is true, complete and accurate.
  
  First NameLast Name
- Social Security Number
  999-99-9999
- Participant Signature
  
  Clear
- Date Signed
  
  MonthDayYear
  mm-dd-yyyy
- Parent Signature (if applicable)
  
  Clear
- Date Signed
  
  MonthDayYear
  mm-dd-yyyy
- Director's Signature
  
  Clear
- Name
  
  First NameLast Name
- Current Grade
- Graduation Year
- Careers your interested in:
- Did anyone refer you?
- Who?
- Locations your interested in(Check all that apply)
- Which of the Florida’s State Universities or Colleges are of interest to you? Check all that applies
- Are you interested in attending Palm Beach State College?
- When do you want to start college?
- Are you planning on doing Fafsa?
- Why?
- Bright Futures
- Scholarships
- What do you want to study in college?