Metropolitan Community College-EOC-Participant Form

EOC Participant Information Form

3100 Main Street, Suite 100 Kansas City, Missouri 64111 (816) 604-4400

The following information is kept secure and confidential.

Military Status

	Yes	No
Veteran
Spouse of Active Duty Military
Active Duty Military
Child of Active Military

Disability

YesNo
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Number in Household
Employment Status

Full-timePart-timeUnemployed
Provide over 50% support for children/dependents?*

YesNo
Check any that apply

In Legal GuardianshipEmancipated Minor by CourtIn Foster CareWard of the CourtUnaccompanied Homeless Youth or Self-supporting and at risk of being homelessSince age 13: Both parents were deceased
Taxable household income last year*
Taxable household income level*

$0 - $21,870$21,871 - $29,580$29,581 - $37,290$37,291 - $45,000$45,001 - $52,710$52,711 - $60,420$60,421 - $68,130$68,131 - $75,840$75,841 and over
Ethnicity: Are you of Hispanic, Latino, or Spanish origin?

YesNo
Check all that apply

American Indian/Alaska NativeAsianBlack/African AmericanWhiteNative Hawaiian/Other Pacific IslanderOther
Receiving Services from other Federally Funded Program?

Upward BoundUpward Bound Math ScienceVeterans Upward BoundStudent Support ServicesTalent SearchGEAR UPOther
EOC Services Requested

Academic AdvisingCareer CounselingPersonal CounselingFinancial/Economic AdvisingFinancial Aid Application AssistanceAdmission Application AssistanceHigh School Equivalency Assistance

Educational Data
High School Graduate?*

YesNo
Enrolled in High School?*

YesNo
High School Grade Level*
Received a High School Equivalency diploma?*

YesNo
Enrolled in High School Equivalency program?*

YesNo
What level did you enroll in High School Equivalency program?*

9th-11th grade12th grade

Educational Data Questions

	Yes	No
In College Classes Now?
Postsecondary stopout (Have not been enrolled in college classes for at least one semester)
Completed 4-yr degree?

How did you hear about EOC? (i.e. Presentation to Center H.S. on 1.15.21)
Do you wish to have us contact you to schedule a follow-up appointment?

YesNo
We are here to serve you when you are interested in furthering your education.

https://mcckc.edu/eoc

http://www.studentaid.gov/
Have you received EOC services previously?

YesNo
If so, approximately how long ago?
I hereby certify that the above information is accurate and complete to the best of my knowledge. The EOC is 100% funded by the United States Department of Education.
Signature of Participant/Parent*

Clear
Attach Required Documents (i.e. tax forms, Social Security benefits statement, residency documentation, etc.)

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Attach Required Documents (2)

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Attach Required Documents (3)

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