Elizabeth City State University-EOC-Application Form

Elizabeth City State University
EDUCATIONAL OPPORTUNITY CENTER PROGRAM

Application for Services

Personal Information
Name*

First NameMiddle InitialD
Social Security Number
999-99-9999
Date of Application*

MonthDayYear
mm-dd-yyyy
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
mm-dd-yyyy
Email Address*
example@example.com
Day Phone
(999)999-9999
Cell Phone*
(999)999-9999
Evening Phone
(999)999-9999
Emergency Contact
Name*

First NameLast Name
Phone*
(999)999-9999
Relationship*

Needs Assessment

Needs Assessment -Please check your current needs*

	Yes	No
1. I need Educational Advising/Coaching
2. I need Career Information/Advising
3. I need Financial Literacy Activity/Information
4. I need Computer Literacy Skills/Information
5. I need Study & Test Taking Skills Activity
6. I need Financial Aid Advising/Information
7. I need FAFSA (Federal Financial Aid) Assistance
8. I need Scholarship Information/Assistance
9. I need College Admissions Application
10. I need College Application Fee Waiver
11. I need Tours/Information of regional College/University
12. I need Assistance with Default Loans
13. I need Re-entry/Transfer Information/Assistance
14. I need GED (General Equivalency Diploma) Information/Referral/Assessment
15. I am currently sharing housing due to economic hardship or loss of housing, awaiting foster care placement, living in a foster home, residing in a group home or emergency/transitional shelter.

I am currently a participant in the following program(s):*

Educational Opportunity Centers (EOC)Upward BoundTalent SearchStudent Support Services (SSS)Veterans Upward BoundRonald E. McNair Post-Baccalaureate Achievement ProgramUpward Bound Math-ScienceNONE

Educational Assessment
High School/GED: Have you completed High School?*

YesNo
Currently enrolled/Name of HS:
Please select*

H.S. GraduateG.E.D. GraduateNot completed
Notes:

First Generation Status
Did either of your parents graduate from a 4-year college prior to you turning 18 years of age?
*Please provide this information only for those parents/guardians living in your former household.
Mother/Female Guardian:*

YesNo
Father/Male Guardian:*

YesNo
List Institution (community college or university):
List Institution: (community college or university

Release Forms
School Records

I grant Educational Opportunity Centers (EOC) Program permission to obtain academic records, college admissions enrollment, financial aid and scholarship information that is necessary to assist in achieving my education goals.

Media Release

I hereby grant TRIO Educational Opportunity Center (EOC) and Elizabeth City State University the irrevocable right and permission to use and distribute video and audio footage and/or still photographs ("media") of me that are taken during my participation in any TRIO-EOC event and to promote or advertise the program events and or exhibit how federal funds are utilized to support students.
FERPA RELEASE: I understand that the media may be protected by the Family Educational Rights and Privacy Act ("FERPA") as education records. I hereby authorize the TRIO Educational Opportunity Center (EOC) and Elizabeth City State University to release the media from any TRIO-EOC events to faculty, staff, students, and visitors to of the University, which may include the general public. The purpose of the disclosure is to advance the educational mission of the TRIO - EOC program. I hereby warrant that I am nineteen years old or more and competent to contract in my own name. This release is binding upon me and my heirs, assigns, and personal representatives. This consent shall remain in effect until revoked. A copy of this Consent shall have the same force and effect as the original.

I understand that the above information will be kept confidential and used solely in support of my educational and career goals.

All the information provided is true and complete to the best of my knowledge.
Applicant signature:*

Clear
Date*

MonthDayYear
mm-dd-yyyy