Central Washington University-EOC-Intake Form

Central Washington University
SCW TRIO-EOC
Intake Form

First NameMiddle InitialLast Name

MobileHomeWorkMessage

mm-dd-yyyy

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

U.S. citizenPermanent residentN/AOther

	Yes	No
Father
Mother

This amount can be found on either line 15 of the 2020 IRS 1040 Tax Return Form or line 11b of the 2019 IRS 1040 Tax Return Form

Information on schools and colleges (admissions, transfer credits, placement testing, etc.)Financial aid (FAFSA, scholarships, loans)Academic support and career planningHigh school and GED informationOther

Information provided to the CWU TRIO-EOC Program is confidential and will not be released without the student's permission.

By signing below, I authorize the CWU TRIO-EOC Program to receive and release information to and from all applicable educational and career institutions to assist me in my educational planning; enrollment verification; and securing financial aid opportunities. Additionally, my information may be released to the U.S. Department of Education to demonstrate program effectiveness, when requesting renewed funding.

I verify that the information provided in this intake application is true and accurate.

mm-dd-yyyy

Potential first-generation college student (neither of the participant's parents obtained/earned a Bachelor's degree).Low-income eligible based on the following: (select the one that applies)

Family Size of 1 person with a Taxable Income of no more than $19,320.Family Size of 2 people with a Taxable Income of no more than $26,130.Family Size of 3 people with a Taxable Income of no more than $32,940.Family Size of 4 people with a Taxable Income of no more than $39,750.Family Size of 5 people with a Taxable Income of no more than $46,560.Family Size of 6 people with a Taxable Income of no more than $53,370.Family Size of 7 people with a Taxable Income of no more than $60,180.Family Size of 8 people with a Taxable Income of no more than $66,990.