Kent State University-EOC-Application Form

NAME:*

First NameMILast Name

ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PREFERRED PHONE#:*

(999)999-9999

ALTERNATE PHONE#:*

(999)999-9999

EMAIL ADDRESS:*

example@example.com

GENDER:*

MALEFEMALENon-Binary

BIRTH DATE:*

mm-dd-yyyy

AGE:*

RACE (CHECK ALL THAT APPLY):*

U.S. CITIZEN?*

YESNO

PERMANENT RESIDENT?*

YESNO

If NOT a Permanent Resident or U.S. Citizen, are you an ELIGIBLENON CITIZEN? (Must provide copy of immigration document)*

YESNON/A

VETERAN?*

YESNO

What is your veteran connection status?*

Do you have a H.S. DIPLOMA OR EQUIVALENT?*

YESNO

Have you ATTENDED COLLEGE IN THE PAST?*

YESNO

Are you pursing a FOUR-YEAR DEGREE?*

YESNO

Are you pursuing a CERTIFICATE OR TWO-YEAR COLLEGE DEGREE?*

YESNO

Are you CURRENTLY ENROLLED IN:*

ASPIRE CLASSES / ADULT DIPLOMA PROGRAM / NONCREDIT CLASSESCOLLEGE CLASSES

What is your current level of education?*

Are you currently a participant in any of the federal programs listed below?*

Program Services Needed*

I need to complete my high school diploma or GEDI need assistance to apply to college/vocational schoolI need assistance applying for Financial AidN/A

Additional referral services needed:*

PARENT/GUARDIAN COMPLETED A FOUR-YEAR BACHELOR’S DEGREE?*

YESNO

FAMILY SIZE (INCLUDE SELF):*

HOUSEHOLD TAXABLE INCOME LAST YEAR:*

NONE

I authorize the exchange of information between the Educational Opportunity Center (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 complete and correct in every respect.

Signature*

Date*

mm-dd-yyyy

Parent's Signature

Parent's Printed Name*

First NameLast Name

Parent's Email*

example@example.com

Parent's Phone Number*

(999)999-9999

Kent State University Educational Opportunity Centers