Del Mar College-EOC-Application Form

Del Mar College Educational Opportunity Center Participant Application

STEP 1
STEP 1

Please answer the following questions about yourself.
a. What is your name?*

First NameMiddle InitialLast Name
b. What is your mailing address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
d. What is your cell phone number?*
(999)999-9999
e. If in high school, please include parent/guardian's phone number.
(999)999-9999
f. What is your work phone number?
(999)999-9999
g. What is your e-mail address?*
example@example.com

STEP 2
STEP 2

Please answer the following questions about yourself.
a. What is the name of the college you attend (if applicable)?
c. What is your student ID number (if applicable)?
d. What is your social security number?*
999-99-9999
e. What is your birthdate?*

MonthDayYear
mm-dd-yyyy
f. Are you Hispanic or Latino?*

YESNO
g. What is your race? (Please check all boxes that describe you.)*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite
h. What is your gender?*

FemaleMale

STEP 3
STEP 3

Please answer the following question about yourself.
a. Are you a U.S. Citizen?

YESNO, but I am a Permanent Resident.NO; I am not a U.S. citizen, and I am not a permanent resident.
My Permanent Resident Alien Number is:

STEP 4
STEP 4

Please answer the following questions about your parents and yourself.
a. Has your mother received/earned a baccalaureate degree (4 year degree)?*

YESNO
b. Has your father received/earned a baccalaureate degree (4 year degree)?*

YESNO
c. Which parent did you regularly reside with and receive support from during your childhood (i.e., until you were 18 years old)?

Both Mother and FatherNeither Mother nor FatherMother onlyFather only

STEP 6
STEP 6

You must answer the following questions about yourself if you are at least 24 years old or you answered YES to any question in STEP 5. Your parent(s) must answer the following questions about themselves if you are less than 24 years old and you answered NO to all questions in STEP 5.
a. What is the total number of persons (including you) in your family unit?*
b. What was your family's taxable (not total) income from the last calendar year? (Please check only one box. Then, provide the requested income information.)*

My family's taxable (not total) income from the last calendar year was:My family did not file a federal income tax return for the last calendar year. My family's total income from the last calendar year was:My family had no taxable income during the last calendar year.
My family's taxable (not total) income from the last calendar year was:*
Note: Taxable income can be found on the federal income tax return. On IRS Form 1040, see line 15. On IRS Form 1040A, see line 27. On IRS Form 1040EZ, see line 6.
My family's total income from the last calendar year was:

Cancelof
My family did not file a federal income tax return for the last calendar year. My family's total income from the last calendar year was:*

STEP 7
STEP 7

Please read the following statement and then sign and date below it. If your less than 24 years old and answered NO to all the questions in STEP 5, your parent or legal guardian must also read the following statement and then sign and date below it.
Did you receive test accommodations while in the school?

YesNo
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Signature of Student's Parent or Legal Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Determination of Applicant Need for Project Services
Educational Opportunity Center (EOC)

Determination of Applicant Need for Project Services (34CF644.4)
1. Did you graduate from high school or earn a High School Equivalency (HSE) certificate?*

YES. I earned a high school diploma.YES. I earned an HSE certificate.NO, but I am enrolled in an alternative adult education program.NO, and I am not enrolled at any high school or any adult education program.No, I'm a high school senior.
School Name
High school graduated from:*
High school location:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year HSE earned:*
State HSE earned in:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Are you currently enrolled in college or at a vocational/technical institution (education beyond grade 12)?*

YESNO
If "YES", please list the college(s) or institution(s).*
I am interested in enrolling in (check all that apply):*

CollegeVocational/technical school
3. Have you ever been enrolled in college or at a vocational/technical institution (education beyond grade 12)?*

YESNO

If "YES", please list the college(s) or institution(s).

	Name	First Date Enrolled	Final Date Enrolled
1.
2.

4. I am interested in receiving and/or assistance with applying for (check all that apply): (34CFR644.3(a)(3)), (34CFR644.4(c))*

Academic Advice/CounselingAdmission (including transfer assistance) to a college or vocational/technical institution (education beyond grade 12)Financial aid that can help me pay the cost of attending a college or vocational/technical institution (education beyond grade 12)TSIA2 VoucherGED Tuition Assistance
5. Are you the spouse of child of an active duty member of the U.S. military?*

YESNO
Spouse or Child?*

SpouseChild
6. How did you hear about us?
By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of the student’s official academic records to the TRIO Educational Opportunity Center (EOC) at Del Mar College in Corpus Christi, Texas, understanding that the information in these records will be used only to assess the student’s need for TRIO program services, discern the student’s educational progress, evaluate the effectiveness of TRIO program activities, and fulfill TRIO program-reporting requirements. Finally, I authorize TRIO EOC to use the student’s name, statements and likeness, without charge, for promotional purposes in TRIO EOC publications, advertising, video, and other formats.
Applicant Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
If under age 24, please include parent signature

Clear
Note: Your EOC Advisor/Coordinator will review your responses to the above questions and work with you to develop a plan that meets your academic needs.

Del Mar College Educational Opportunity Center Participant Application

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

STEP 7

Educational Opportunity Center (EOC)