Western Kentucky University-EOC-2022 Application Form

All fields marked with * are required and must be filled.

1. Name*

First NameM.I.Last Name

2. Social Security Number*

999-99-9999

or WKU Student ID or KCTCS ID

3. Local address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4. County of residence: select one*

5. Telephone*

(999)999-9999

6. Email address*

example@example.com

7. Date of Birth*

mm-dd-yyyy

8. Gender*

MaleFemaleOther

9. Ethnicity: Are you Hispanic/Latino*

YesNo

If "No", please select from below*

10. Is English your first language?*

YesNo

11. U.S. Citizen?*

YesNo

If not a US Citizen, eligible non-citizen number*

If not a US Citizen, Place of Birth*

12. Please check if you are a (an)*

13. Please indicate your household's TAXABLE INCOME range from last year*(2021 tax form 1040: Line 15)*

14. Total number of people in your household (include yourself)*

15. Are you or anyone in your household receiving*

16. Did either of your parents, or the parent you lived with prior to your 18th birthday, receive a 4-year college degree?*

YesNo

17. What is your current education status?*

Name of the high school

Name of the college

Are you currently enrolled in a GED Program?*

YesNo

18. I have a desire to enroll in*

19. I need information on or assistance with (Check all that apply)*

20. I grant permission for my name/photo to be released for advertising purposes.*

YesNo

WKU’s EOC program is a USDE grant funded project 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 correct to the best of my knowledge.

Both a parent signature and an applicant signature are required if the applicant is under 18 years of age.

21. Today's Date*

mm-dd-yyyy

22. Participant Signature

23. Parent/Guardian Signature (if under 18)

EDUCATIONAL OPPORTUNITY CENTERS APPLICATION FORM