Delta Sigma Theta Incorporated-EOC-Intake Form

MEOC Confidential Client Intake Application
The Maryland Educational Opportunity Center (MEOC), a program of the national office of Delta Sigma Theta, Inc. funded by the U.S. Department of Education, provides free postsecondary planning assistance to eligible program participants.
Name*

FirstMILast
Would you prefer to fill in your full SSN or just the last 4 digits*

Full SSNLast 4 digits
Soc. Sec. No.*
999-99-9999
Last four digits of Soc. Sec. No.*
9999
Alien Registration Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
(999)999-9999
Cell/Work Phone*
(999)999-9999
Email*
example@example.com
Date of Birth*

MonthDayYear
mm-dd-yyyy
Age*
Gender*

MaleFemaleNon-BinaryPrefer not to answer
Citizenship*

U.S. CitizenEligible NoncitizenOther
Marriage Status*

MarriedSingleSeparatedDivorcedWidow/er
Ethnicity*

Hispanic/LatinoAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMore than one race
Physical or Learning Disability
Military Status*

Non-VeteranVeteranActive Duty MilitaryParent Active Duty MilitarySpouse Active Duty Military
Family Size*

Annual taxable income range for last year (If you are a dependent, do both.)

Rows	You	Parents
$0 — $ 0
$1 — $19,320
$19,321—$26,130
$26,131—$32,940
$32,941—$39,750
$39,751—$46,560
$46,561—$53,370
$53,371—$60,180
$60,181—$66,990
$66,991—Over

Income Sources*

EmploymentPublic AssistanceSocial SecurityUnemployment CompensationVeterans BenefitsNoneOther
Please type other income source here*
Currently Employed*

YesNo
Does your father have a bachelor’s degree?*

YesNo
Does your mother have a bachelor’s degree?*

YesNo
Your current education status:*

In high schoolHigh school dropoutHigh school/GED graduateEnrolled in GED programEnrolled in college/tech schoolPotential college transfer studentCollege/tech school dropoutCollege/tech school graduate
Grade*
School*
Highest grade completed*
Year*
Where*
Where*
Degree*
Services Requested*

AdmissionsCollege TransferFinancial AidCareer GuidanceGED ReferralGED Practice TestFinancial LiteracyOther
Are you currently participating in an Upward Bound, Talent Search or Student Support Services program?*

YesNo
If yes, name of program*
Select One:*

Gear upStudent Support ServicesTalent SearchUpward BoundUpward Bound (UBMS)Veterans Upward BoundOther federally funded programServed by more than oneNo response/unknownOther
Name of MEOC counselor who will assist you:*
How did you hear about us?*

Mall AdvertisementCommunity EventMet with a counselor at an agencyMEOC Virtual Open HouseReferral from an MEOC ParticipantFAFSA FestIntern ReferralOther
Please indicate the community event you attended*
Please indicate the agency where you met the counselor*
Signature certifies that the above information is true and complete. I hereby authorize the Maryland Educational Opportunity Center to release and receive information, including education records, to assist me with my educational planning.
Client name*

First NameLast Name
If you have trouble signing below, please type your name above and check the box below.*

By checking this box and typing my name above, I am electronically signing my application.
CLIENT*

Clear
Parent Name*

First NameLast Name
If you have trouble signing below, please type your name above and check the box below.*

By checking this box and typing my name above, I am electronically signing my application.
PARENT*

Clear

MEOC Confidential Client Intake Application