TRIO Educational Opportunity Center at McLennan Community College

TRIO Educational Opportunity Center
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Name*

First NameMILast Name
Today’s Date*

MonthDayYear
mm-dd-yyyy
Are you fluent in English?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
(999)999-9999
Other Phone Number: *
(999)999-9999
Email Address:*
example@example.com
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemale
Ethnicity: (Select only one)*

Hispanic/Latino (Mexican, Puerto Rican, Cuban, Central/South American, or other Spanish culture)Non-Hispanic/Latino
Race: (Select all that apply regardless of Ethnicity)*

American Indian or Alaskan NativeAsian, Japanese, Chinese, Vietnamese, Korean, FilipinoBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite, Anglo, Caucasian
Citizenship*

US CitizenPermanent ResidentNeither
If Permanent Resident, A#*
Did either one of your parents graduate from college with a 4-year college degree?*

YesNo
If yes...

MotherFatherBoth
Number of Family Members in Your Household?*
Include yourself, parents, siblings, spouse, children, and any other individual who is receiving more than half of their support from you or your parents.
Income Statement - Your Taxable Income for the previous year was the following:*
Please note taxable income is usually lower than Adjustable Gross Income (AGI). This information can be found at the bottom of the first page of most tax forms. Annual taxable income can be found on page 2 of most tax forms. Please call (254) 299-8599 if you have questions or need assistance locating this information.
What are your Current Educational Goals?*

Unknown/UndecidedHigh School DiplomaGED/ High School EquivalencyCertificateAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate Degree
College(s) Considering:
1.*
2.*
I am undecided on College Considering*

YesNo
Degree Program(s):
1.*
2.*
I am undecided on Degree Programs*

YesNo
Intended Career Field:*
I am undecided on my Career Field*

YesNo
Have you ever received services from TRiO EOC @ MCC before?*

YesNoUnsure
Which year?*
Have you participated in any of the following programs SINCE SEPTEMBER 1? (Check all that apply)*

Not ApplicableTRIO Upward BoundTRIO Upward BOUND Math & ScienceTRIO Student Support ServicesTRIO Talent SearchTRIO Veterans Upward BOUNDGEAR UP
Current Education Status: (Please check you current educational status. Please check only one.)*

High School Non-Senior (grades 9, 10, or 11)High School SeniorHigh School Stop outHigh School GraduateEarned GEDCollege StudentCollege Stop outPostsecondary Certificated Earned (1 Year)College Graduate
High School Non-Senior (grades, 9, 10, or 11) - High School:*
High School Non-Senior (grades, 9, 10, or 11) - Grade: *
High School Senior - High School:*
High School Senior - Class of:*
High School Stop out - High School:*
High School Stop out - Check as many as apply*

Dropped out in 9th GradeDropped out in 10th GradeDropped out in 11th GradeDropped out in 12th GradeNot enrolled in an Alternative Education/GED
High School Graduate - High School:*
High School Graduate - Year Graduated:*
Earned GED - Year Earned:*
Earned GED - Program Name:*
College Student - Currently enrolled at:*
College Student - # of Hours/Years:*
College Student - Major:*
College Student - Are you interested in transferring to another college?*

YesNo
College Stop out - Last College attended:*
College Stop out - Semester/Year*
Postsecondary Certificate Earned (1 Year) - Year Earned:*
Postsecondary Certificate Earned (1 Year) - College:*
College Graduate - Degree(s) Obtained:*

Associate Degree (2 year)Bachelor's Degree (4 year)Other
College Graduate - Degree(s) Obtained - Associate Degree (2 year) - Year Earned:*
College Graduate - Degree(s) Obtained - Associate Degree (2 year) - Major:*
College Graduate - Degree(s) Obtained - Bachelor's Degree (4 year) - Year Earned:*
College Graduate - Degree(s) Obtained - Bachelor's Degree (4 year) - Major:*
Military-Connected (Check any that apply)*

Not ApplicableVeteranSpouse of Active Duty MilitaryActive Duty MilitaryChild of Active Duty Military
College Admissions Application Status:*

I have completed a college admission applicationI have not applied yet
I have completed a completed a college admission application to*
Semester/Year:*
Student Financial Aid Application*

I have completed a financial aid and/or scholarship applicationI have not applied yetFinancial Aid Suspension Appeal
Semester/Year*
EOC helps you plan your educational future. Which of the following services would be helpful to you? (Check all that apply.)
Financial Aid Assistance*

Financial Aid Application (FAFSA)Loan ApplicationLoan DefaultScholarship AssistanceFinancial Aid VerificationBudgeting for CollegeOther
College Admissions Assistance*

Admissions ApplicationApplication Fee WaiverCollege SearchTesting Fee WaiverTransfer AdvisingCollege Re-entryTSIA boot campOther
Other*

Academic PlanningCareer AdvisingGED/High Scholl EquivalencyHigh School Re-entryOther
Consent*

I certify that all of the above information is true and completed to the best of my knowledge. I certify the information provided concerning citizenship is accurate. I certify the information concerning taxable income is accurate. I authorize the use of my photograph in TRIO EOC @ MCC publications and media releases. I authorize TRIO EOC @ MCC access to my high school and college information to determine program eligibility, to assist, and to verify high school and college enrollment to meet program reporting requirements of the U.S. Department of Education. TRIO EOC @ MCC is authorized to access or release family income, admissions, academic and/or financial aid information deemed necessary to assist me in achieving my educational goals. This includes my grades, test scores, enrollment status, and student financial aid records. I authorize TRIO EOC @ MCC to release information from my participant file to state and federal agencies when required by law or regulations.
I would like to receive text messages regarding my appointments, deadlines, scholarships, and other necessary communication.*

YesNo
Best Phone Number*
(999)999-9999
Participant Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature (Only required for Dependent Students)

Clear
Date

MonthDayYear
mm-dd-yyyy
Share with us the name of the person and/or department who referred you or what event you participated/attended? *
TRIO Educational Opportunity Center at MCC is 100% federally funded by the U.S. Department of Education with an annual budget of $232,050.

McLennan Community College is dedicated to providing equal opportunities to all individuals and does not discriminate against any individual regardless of race, color, religion, national or ethnic origin, gender, disability, age, veteran status, genetic information, sexual orientation, gender identity, pregnancy, or other legally protected category in its educational programs, activities, or employment as required by Title VI and Title VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Educational Amendments Act of 1972, and the Age Discrimination Act of 1978.