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
Today's Date*

MonthDayYear
mm-dd-yyyy
How were you referred to the EOC?*
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:*

Referral to GED programs or testingCollege ToursApplying for admission to collegeFinancial LiteracyApplying for financial aid to help pay for college costsWorkshopsSelecting a career or major.Scholarship SearchReferrals to tutoring, counseling or other servicesOther
PERSONAL INFORMATION
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
(999)999-9999
Personal Email Address*
example@example.com
Birth Date*

MonthDayYear
mm-dd-yyyy
Gender*
Gender*

FemaleMale
Age
PARTICIPANT PROFILE
Are you a US Citizen?*

Yes, I am a U.S. Citizen (U.S. National)No, but I am a permanent resident or other eligible noncitizen.No, I am not a citizen or eligible noncitizen.
Social Security Number
999-99-9999
Alien Registration Number*
Citizenship Status*
What is your current dependency status?*

DependentIndependent
Reason for qualifying as status selected above*
What is your primary language spoken in your home?*

EnglishSpanishCreoleOther
What is your current status in the military?*

Active DutyReservesVeteranNone
Are you the dependent or spouse of a veteran, reserved, or active service member?*

YesNo
If Yes, which best describes your current status?

Dependent ChildWife/Husband
As of today, what is your marital status?*

Single (never married)MarriedSeparatedDivorced or Widowed
What is Your Ethnicity?*

Hispanic or LatinoNot Hispanic or Latino
Please Select One or More Races*

American Indian or Alaska Native, non-Hispanic/LatinoAsian, non-Hispanic/LatinoBlack or African American, non-Hispanic/LatinoHispanic/Latino of any raceNative Hawaiian or Other Pacific Islander, non-Hispanic/LatinoTwo or more races, non-Hispanic/LatinoWhite, non-Hispanic/LatinoOther
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)?*

Both mother and fatherNeither mother nor fatherMother onlyFather only
2. Did the parent(s) listed above receive a four-year college degree?*

Both mother and fatherNeither mother nor fatherMother onlyFather only
EDUCATION
What is your current educational status?*

9th grade10th grade11th grade12th gradeHigh School Dropout (under age 19)High School Dropout (age 19 or older)High School/GED GraduateGED StudentCollege StudentOther
Do you receive free and reduced lunch?*

YesNoNot Applicable
Student ID Number
(N/A if you are not in school)
High School Attended
Colleges you are interested in:*
Career, Area or College Major of Interest (Or Undecided)*
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
Parent Phone Number
(999)999-9999
Parent Email
example@example.com
Income Tax Form (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)*
2. Taxable Income from 2024 Income Tax Form 1040 Line 15 was:

From $0 to $23,475From $23,476 to $31,725From $31,726 to $39,975From $39,976 to $48,225From $48,226 to $56,475From $56,476 to $64,725From $64,726 to $72,975From $72,976 to $81,225$81,226+
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, {pleaseType} 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.
Please type name*

First NameLast Name
Social Security Number/Alien Registration Number
999-99-9999
Participant Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Parent Signature (if dependent)

Clear
Date Signed

MonthDayYear
mm-dd-yyyy