Western Kentucky University-EOC-Application Form

EDUCATIONAL OPPORTUNITY CENTERS APPLICATION FORM

The following information will be used to determine eligibility for services from EOC for 2021-22 project year
1. Name*

First NameM.I.Last Name
2. Social Security Number*
999-99-9999
3. Local Address*

Street Address

Street Address Line 2

CityState

Zip Code
4. County of residence: select one*
5. Telephone*
(999)999-9999
Phone Type*

CellOther
Okay to text?*

YesNo
6. Email Address*
example@example.com
7. Date of Birth*

MonthDayYear
mm-dd-yyyy
8. Age*
9. Gender*

MaleFemaleOther
10. Ethnicity: Are you Hispanic/Latino?*

YesNo
If "No", please select from below*

American Indian or Alaska NativeAsianBlack or African AmericanWhiteNative Hawaiian or Other Pacific IslanderTwo or more races
11. Is English your first language?*

YesNo
12. U.S. Citizen?*

YesNo
If not a US Citizen, eligible non-citizen number*
If Not a US Citizen, Place of Birth*
13. Please check if you are a (an)*

No response/UnknownVeteranActive Duty MilitarySpouse of Active Duty MilitaryChild of Active Duty Military
14. As of today, are you*

SingleMarriedSeparatedDivorcedWidow/widower
15. Are you now or have you been*

HomelessIn or aging out of foster careIn or aged out of guardianshipDoes not apply
16. Did you file taxes last year?*

YesNo
17. If under the age of 24, did your parent(s) file taxes last year?*

YesNo
18. Please indicate your household’s TAXABLE INCOME range from last year*(2020 tax form 1040: Line 15)*

Less than $19,320$19,321 - $26,130$26131 - $32,940$32,941 - $39,750$39,751 - $46,560$46,561 - $53,370$53,371 - $60,180$60,181- $66,990More than $66,990
19. Total # in household including self*

123456789+
16. Number of Dependents: Are you providing more than 1/2 of the support for any children or other dependents (not including a spouse)?*

YesNo
17. For how many dependents are you providing this support?*
18. Total # in household (including yourself)*
21. Family's taxable income*

Did not file taxes in 2019.Family Income (2019 1040 Tax Form Line 11B)
Enter income number from tax form
20. Are you or anyone in your household receiving*

SSISNAPFree or Reduced-Price School LunchTANFWICDoes not apply
21. Did either parent receive a 4-year degree before you turned 18?*

YesNo
22. What is your CURRENT educational status? Select ONE*

Completed 4-yr college degreeCompleted 2-yr degree or certificateCurrently enrolled in College/Tech SchoolDropped out of College or Tech SchoolHigh School graduateGED graduateCurrently enrolled in high schoolCurrently enrolled in a GED programDid not complete high school and not enrolled in GED program
Education Information
21. Did either of your parents, or the parent you lived with prior to your 18th birthday, receive a 4-year college degree?*

YesNo
22. What is the highest grade you completed?*

8th grade or below91011Current High School SeniorHigh School/GED Graduate1 year college2 years college3 years college4-year degree
Have you completed a 4-year college degree?

YesNo
If a current High School Senior, list High School name
23. Are you currently enrolled in College/Tech school*

YesNo
What is the name of the school?
24. Are you currently enrolled in a GED Program?*

YesNo
County; select one
25. Have you ever attended a community or technical college or a university in the past?*

YesNo
What is the name of the school?
26. Did you earn a certificate or associate degree?*

YesNo
Year*
What grade were you in when you last attended school?*
27. I have a desire to enroll in*

GED programVocational/Technical School2-year CollegeTransfer from 2-yr to 4-yr program4-year College or UniversityOther

27. When do I desire to enroll (Enter year on line provided)*

	Year
Fall
Winter
Spring
Summer
Undecided

28. When do I desire to enroll

FallWinterSpringSummerUndecided
29. I Need Information On (Check all that apply)*

GED ProgramsGoing to CollegeSchool Admission RequirementsFinancial Aid ResourcesAcademic Loan RehabilitationCareer OptionsFinancial Literacy
30. I Need Assistance With (Check all that apply)*

Completing Application(s) for AdmissionCompleting the FAFSAFiling Financial Aid AppealOther
31. I grant permission for my name/photo to be released for advertising purposes.*

YesNo
32. Who referred you to the EOC application*
WKU’s EOC program is a USDE grant funded project ($273,793.00) which does not discriminate on the basis of age, color, national origin, sex, handicap, or religion, in admission policies, the administration and implementation of educational policies, employment, or any other activity.

I hereby authorize the exchange of information between the Educational Opportunity Centers (EOC) and other agencies, as necessary to assist me in achieving my educational goals. By signing and dating this application, I certify that the information provided is complete and correct in every respect.

*I certify that, to the best of my knowledge, all information given is correct*

Both a parent signature and an applicant signature are required if the applicant is under 18 years of age. A parent signature is not required but is preferred if the applicant is 24 years of age or younger and was listed as a dependent in 2020 tax filings.
33. Participant Signature*

Clear
34. Today's Date*

MonthDayYear
mm-dd-yyyy
35. Parent Signature

Clear

Education Information