Baton Rouge Community College-EOC-Application Form

Baton Rouge Community College Educational Opportunity Center

U.S. Department of Education TRIO Program
- The Baton Rouge Community College TRIO Educational Opportunity Center Program is a federally funded TRIO program and all services are provided to program participants free of charge. All individuals who meet the eligibility requirements of this program are provided information regarding financial and academic assistance necessary for them to enter higher education for the first time or to return if they have dropped out.
- Name:*
  
  First NameLast Name
- Social Security Number:
  999-99-9999
- DOB:*
  
  MonthDayYear
  mm-dd-yyyy
- Biological Sex:
  
  malefemaleI do not wish to discloseOther
- Our office understands that the language used in this survey may not accurately reflect members of the LGBTQ+ community. Unfortunately, these questions are required by the U.S. Department of Education. We also understand these questions may be triggering for some individuals. Our program supports and advocates for mental health and supports all of our participants.
- What are your pronouns?
  
  She/HerHe/HimThey/ThemOther
- Marital status:
  
  singlemarriedseparateddivorcedwidowed
- Address:*
  
  Address:
  
  Street Address Line 2
  
  City:State:
  
  Zip:
- Phone number:*
  (999)999-9999
- Email:*
  example@example.com
- U.S. Citizen
  
  YesNo
- If 'no' have you applied for permanent status?
  
  YesNo
- Alien Number
- Ethnic Background:
- Do you consider yourself to be Hispanic or Latinx?*
  
  YesNo
- - (Select all that apply)*
  
  American Indian or Alaska Native AsianAsian AmericanBi-RacialBlack / African AmericanWhiteNative Hawaiian or Pacific IslanderHispanicOther
- Optional: The U.S. Department of Education actively assists the folowing persons. Please check the box if you meet either of these criteria:
- Disability:
  
  DisabilityOther
- Veteran:
  
  Active DutyReservistSpouse or dependent of military personnel
- Employment Status:
  
  Full TimePart-TimeUnemployedSelf-Employed
- Income Source:
  
  SelfSpouseSocial Security Benefits / SSIWelfareVeterans Benefits
- Taxable Income:
  
  $0 - $18,735$18,736– $25,635$25,636– $31,995$31,996– $38,625$38,625 – $45,255$45,256 – $51,885$51,886– $58,515$58,516 – $65,145$65,146– Over
- Form 1040 (line 43)
  
  Form 1040A (line 27)
  
  Form 1040EZ (line 6)
- Size of family (including self):
- Highest level of education completed: (Check one)
  
  Some high schoolHigh School GraduateGEDSome collegeCertificate(s)Associate's Degree
- Grade Last Completed
- School Name
- Institution Name
- Certificate(s)
- School Name
- If 'Some High School', Grade:
- If 'High School Senior', School Name:
- If 'High School Senior', Graduation Date:
- If 'GED', Currently enrolled at:
- If 'GED', Completed?
- If 'GED', Graduation date:
- If 'Some College', College Name:
- If 'Some College', Degree Pursued:
- If 'Certificate(s)', Please list:
- If 'Associate's Degree', College Name:
- If 'Associate's Degree', Degree:
- If 'Associate's Degree', Graduation Date:
- Did either of your parents’ GRADUATE college with a 4-year (bachelor’s) degree? (check one)
- Mother:
  
  YesNoUnknown
- Father:
  
  YesNoUnknown
- How did you hear about us?
  
  Adult EdAgencyWorkshop/PresentationFriend/RelativeMail/Flyer
- Name of referring agency, Adult Ed Program, office or workshop location:
- I declare that the information on this form is true to the best of my knowledge. The TRIO Baton Rouge Community College Educational Opportunity Center Program is authorized to access information deemed necessary to assist me in achieving my educational goals or in meeting the reporting requirements of the U.S. Department of Education, to record pertinent facts regarding my eligibility in the Program, services rendered, and placement. A copy of this statement shall serve as such authorization.
- Signature of Applicant:
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Parent Signature (if under 18):
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Services Needed
  
  I need to complete my GEDI need to complete my high school diplomaI need assistance to apply to college/career schoolI need assistance applying for financial aidI need assistance transferring to a four year university
- Special Assistance
  
  Loan Default AssistanceCareer AssessmentSchool or college re-admission assistanceDisability academic support information
- If 'Disability academic support information', please select type
  
  LearningHearingVisualPhysical
- 1. I find it difficult to get started working on projects.
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- 2. Instead of learning something new, I would rather practice something I am good at.
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- 3. Setbacks do not discourage me.
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- 4. I believe that learning should be easy.
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- 5. I am often discouraged when things are hard
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- 6. It is important to me that I do not make mistakes.
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- 7. I often set smaller goals to achieve easier success.
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- 8. I believe in finishing whatever I begin.
  
  Very much like meMostly like meSomewhat like meNot much like meNot like me at all
- I, the under signed, authorize the TRIO Baton Rouge Community College Educational Opportunity Center Program to use photographs and/or videotape with my image in Educational Opportunity Center publications, promotional media, social media, websites and/or news releases.
- Signature of Applicant:
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Parent Signature (if under 18):
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- I {main_name} have read and I understand the provided information and have had the opportunity to ask questions. I understand that my participation is voluntary and that I am under no legal obligations.
  
  By signing, I give my consent to Baton Rouge Community College TRIO Delta Educational Opportunity Center to submit an admission and a financial aid application to post-secondary education programs on my behalf.
- Signature of Applicant:
  
  Clear
- Date:*
  
  MonthDayYear
  mm-dd-yyyy
- Parent Signature (if under 18):
  
  Clear
- Date:*
  
  MonthDayYear
  mm-dd-yyyy

Baton Rouge Community College Educational Opportunity Center