EDUCATIONAL OPPORTUNITY CENTER PROGRAM
Name
*
First Name
Middle Initial
Last Name
Gender
Male
Female
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
mm-dd-yyyy
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
(999)999-9999
Emergency Contact
First Name
Last Name
Phone
(999)999-9999
Relationship
Ethnicity
*
American Indian/ Alaska Native
Asian
Latino/Hispanic
Native Hawaiian/ Pacific Islander
Black, Non-Hispanic
White, Non-Hispanic
Other
Citizenship
*
U.S. Citizen
Eligible Noncitizen
Other
Military Status
*
Veteran
Active Military Duty
Military Spouse
Military Dependent
Non-Veteran
Are you a military dependent
Yes
No
Your current education status
*
Enrolled in HS/GED Program
HS/GED Graduate
Enrolled in College/Tech
College/Tech Graduate
Not Completed
What school do you attend?(place N/A if you are not enrolled in school)
Did your Father graduate from a four-year college/university?
*
Please Select
Yes
No
Did your Mother graduate from a four-year college/university?
*
Please Select
Yes
No
# of people in Household
*
What is your family’s taxable income from the last calendar year?
*
Had no income
$0-$22,590
$22,591-$30,660
$30,661-$38,730
$38,731-$46,800
$46,801-$54,870
$54,871-$62,940
$62,941-$71,010
$71,011-$79,080
$79,081 & above
What is your current labor status ?
*
Employed Full-Time
Employed Part-Time
Unemployed
Receiving Public Assistance
Self-Employed
If “no”, do any of these situations apply?
*
I am in the United States for other than a temporary purpose. Please provide evidence from the immigration and Naturalization Service of your intent to become a permanent resident.
I am a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of Pacifica Islands.
I am a resident of the Freely Associated States- the Federated States of Micronesia, The Republic of the Marshall Islands, or the Republic of Palau.
Program and Services Needed
*
Admissions
Financial Aid
College Counseling
Scholarship Search
Financial Counseling
Career Exploration
Personal Development Counseling
Other
Are you currently participating in an Upward Bound, Talent Search or Student Support Services program?
*
Yes
No
Name of EOC Advisor who will assist you:
*
Please Select
Sherilynn Castel
Kendra Robinson
Amie Davis
Taunya Harris
Danny Hill Jr
Signature certifies that the above information is true and complete.
*
First Name
Last Name
If you have trouble signing below, please type your name above and check the box below.
*
By checking this box I am electronically signing my application
Applicant signature
*
Date
*
-
Month
-
Day
Year
mm-dd-yyyy
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