Piedmont Community College-Roxboro-EOC-High School Application Form

EDUCATIONAL OPPORTUNITY CENTER (EOC)
Piedmont Community College/TRIO
1715 College Drive, Roxboro, NC 27573
Telephone: (336) 599-1181

EOC High School Student Application Form

Student Class*

High School SeniorHigh School Junior

High School Graduation Year*

Participant Status*

New to EOCContinuing EOC Participant

EOC County*

Name*

First NameMILast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Date of Birth*

mm-dd-yyyy

Age*

Gender*

MaleFemale

Home Phone*

(999)999-9999

Mobile Phone*

(999)999-9999

Personal Email*

example@example.com

Citizenship Status*

U.S. CitizenPermanent Resident

Permanent Resident #*

Ethnicity*

EDUCATIONAL ACHIEVEMENT

I have a high school diploma*

YesNo

I plan to obtain a high school diploma:

Year*

School*

COLLEGE PLANS

I plan to _____ college at...*

StartRestartContinue

College*

Semester*

FallSpringSummer

Year*

INTENDED COLLEGE MAJOR/COURSE OF STUDY*

REQUESTED MATERIALS AND SERVICES (Check all that are applicable.)

I need assistance in the following areas:

I have already completed:

SAT ACT Testing; Interested in retaking?*

YesNo

Student Athlete:*

YesNo

Military*

I would like to be considered for the EOC Scholarship!*

YesNo

Are you currently participating in a Talent Search program?*

YesNo

Do either of your parents have a Bachelor’s degree (four-year degree) or higher?*

YesNo

Do either of your parents have an Associate degree (two-year degree) or higher?*

YesNo

Have you been awarded a Pell Grant for college?*

YesNo

What was your family’s taxable income for the previous year?*

What is the number of people living in your household*

Agreements*

I understand that the above information will be held strictly confidential and will be used for statistical and follow up purposes only.I attest that all information provided on this application is true to the best of my knowledge.I grant the Educational Opportunity Center permission to use my name and personal image in all forms of media for lawful purposes.I understand that I (and parents, if necessary) must sign a Hold Harmless form in order to take part in EOC field trips/campus visits.

New Participant Signature*

I grant permission for my student to join The Educational Opportunity Center program and to participate in activities it sponsors.*

YesNo

Parent Signature (if participant is under 18 years old)*