Northeastern State University-EOC-Application Form

Name*

First NameLast Name

Date of Birth

mm-dd-yyyy

Social Security Number*

999-99-9999

Documentation #

if applicable

Address*

Street Address

County

CityState / Province

Postal / Zip Code

County*

Phone Number*

(999)999-9999

Email*

example@example.com

Gender

MaleFemale

Correctional Center?

if applicable

Residency Status

U.S. CitizenPermanent Resident

Military Status

Prior Trio participant (if yes then which one)

Do you have a disability that may require special accommodations during this visit?

YesNo

Ethnicity: (check all that apply)

Marital status:

Income:

How many people live in your home including you?

What was your household income last year (Annual taxable income- form 1040, line 15)*

Source of income

Do you receive child support?

YesNo

Current Education Level (Please check all that apply)*

Dropped out of high schoolHigh school Graduate/GED CompletedCollege/Career Tech IncompleteCompleted Career Tech Certificate or LicenseCompleted Associate’s DegreeCompleted Bachelor’s Degree

What grade

Date

mm-dd-yyyy

Are you currently enrolled in:*

High schoolGED/ABE ClassesCollege, Career Tech, Vocational SchoolNone

what grade

where

Are you interested in furthering your education?

YesNo

If yes, where?

Did either of your parents earn a 4-year degree?*

YesNo

Referred by:

How can EOC assist you*

Filling out FAFSA, discussing grants, loans, or other federal assistanceCareer assessmentStudying and testing for GEDAdmissions (initial or re-entry) assistance to college, career, or vocational schoolOther

Certification/Permission

To be signed by participant and if under 18, parent or Legal Guardian

I certify that the above information is accurate and complete to the best of my knowledge. The Educational Opportunity Center Staff has my permission to receive copies of educational records (official school transcript with test scores, test results: SAT, ACT, etc., basic skills test results, student history file/academic report with test scores, and enrollment information from the National Student Clearinghouse). Permission is also given to post-secondary institutions (universities, colleges, proprietary schools), technical school and/or other educational or other agencies to release to Educational Opportunity Center at Northeastern State University any information or documentation for educational tracking purposes related to the student’s: admissions, enrollment, financial aid, and academic (i.e. transcripts) and other materials necessary for participation in their services. I further understand that all my records will be kept in confidence and in accord with the Privacy Act of 1984. Permission is granted to send enrollment and financial aid information to Educational Opportunity Center of Northeastern State University, 600 N Grand Ave, Tahlequah, OK 74464.
Once signed and dated, this release will be valid throughout the student’s educational career and as long as Educational Opportunity Center has need for the information. It is understood that this information will be handled in a confidential manner and will only be available to EOC program staff and representatives of Federal and State Departments of Education.
Permission is granted to Northeastern State University and Educational Opportunity Center to use information and/or photographs about the student for use in media releases, publications, brochures, newsletters, advertisements, social media, and other promotional uses without notifying the client or legal guardian. Northeastern State University is held harmless of any liability.

Signature of participant*

Signature of parent (if needed)

Date*

mm-dd-yyyy