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

Street Address

Street Address Line 2

City State

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

Cell Other
Okay to text? *

Yes No
6. Email Address *
example@example.com
7. Date of Birth *

Month Day Year
mm-dd-yyyy
8. Age *
9. Gender *

Male Female Other
10. Ethnicity: Are you Hispanic/Latino? *

Yes No
If "No", please select from below *

American Indian or Alaska Native Asian Black or African American White Native Hawaiian or Other Pacific Islander Two or more races
11. Is English your first language? *

Yes No
12. U.S. Citizen? *

Yes No
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/Unknown Veteran Active Duty Military Spouse of Active Duty Military Child of Active Duty Military
14. As of today, are you *

Single Married Separated Divorced Widow/widower
15. Are you now or have you been *

Homeless In or aging out of foster care In or aged out of guardianship Does not apply
16. Did you file taxes last year? *

Yes No
17. If under the age of 24, did your parent(s) file taxes last year? *

Yes No
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- $66,990 More than $66,990
19. Total # in household including self *

1 2 3 4 5 6 7 8 9+
16. Number of Dependents: Are you providing more than 1/2 of the support for any children or other dependents (not including a spouse)? *

Yes No
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 *

SSI SNAP Free or Reduced-Price School Lunch TANF WIC Does not apply
21. Did either parent receive a 4-year degree before you turned 18? *

Yes No
22. What is your CURRENT educational status? Select ONE *

Completed 4-yr college degree Completed 2-yr degree or certificate Currently enrolled in College/Tech School Dropped out of College or Tech School High School graduate GED graduate Currently enrolled in high school Currently enrolled in a GED program Did 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? *

Yes No
22. What is the highest grade you completed? *

8th grade or below 9 10 11 Current High School Senior High School/GED Graduate 1 year college 2 years college 3 years college 4-year degree
Have you completed a 4-year college degree?

Yes No
If a current High School Senior, list High School name
23. Are you currently enrolled in College/Tech school *

Yes No
What is the name of the school?
24. Are you currently enrolled in a GED Program? *

Yes No
County; select one
25. Have you ever attended a community or technical college or a university in the past? *

Yes No
What is the name of the school?
26. Did you earn a certificate or associate degree? *

Yes No
Year *
What grade were you in when you last attended school? *
27. I have a desire to enroll in *

GED program Vocational/Technical School 2-year College Transfer from 2-yr to 4-yr program 4-year College or University Other

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

Fall Winter Spring Summer Undecided
29. I Need Information On (Check all that apply) *

GED Programs Going to College School Admission Requirements Financial Aid Resources Academic Loan Rehabilitation Career Options Financial Literacy
30. I Need Assistance With (Check all that apply) *

Completing Application(s) for Admission Completing the FAFSA Filing Financial Aid Appeal Other
31. I grant permission for my name/photo to be released for advertising purposes. *

Yes No
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 *

Month Day Year
mm-dd-yyyy
35. Parent Signature

Clear

Education Information