Texarkana College-EOC-Intake Form

Educational Opportunity Center at Texarkana College

New Participant Intake Form
The Educational Opportunity Center at Texarkana College is a federally funded TRIO program and all services are provided to program participants FREE OF CHARGE. All individuals who meet the eligibility requirements of this program are provided information regarding financial and academic assistance necessary for them to enter the college of their choice. This is an outreach program of the U.S. Department of Education and Texarkana College.

If you have earned a bachelor’s degree do NOT complete this form!
Name*

First NameMILast Name
Preferred Name:
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
(999)999-9999
Alternate Phone Number:
(999)999-9999
Would you like to receive text messaging with this phone number?*

YesNo
Date of Birth:*

MonthDayYear
mm[-dd-yyyy
Email Address:*
example@example.com
Social Security Number
999-99-9999
Gender:*

FemaleMalePrefer not to answerNon-Binary
Citizenship:*

US CitizenPermanent ResidentNeither
If Permanent Resident, A#*
Ethnicity/Race: Are you Hispanic or Latino?

YesNo
Race (Select all that apply):

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhitePrefer not to answer
Emergency Contact Information
Emergency Contact Person:

First NameLast Name
Relationship:
Emergency Telephone Number:
(999)999-9999
Military Connected
What is your military connection status?*

Not ApplicableActive DutySpouse of Active DutyVeteranChild of Active Duty
Family Educational Background Information
Does either of your parents have a 4-year (bachelor’s) college degree?*

YesNo
Participant Educational Background
What is your current level of education?*

Enrolled in high school (12th grade)Did not finish high school – Not Enrolled in a GED programEnrolled in GED/Alternative EducationHigh school graduateGED graduateStarted College but did not finishVocational/technical school certificateCurrently attending collegeCollege graduate – ASSOCIATES DEGREECollege graduate – BACHELORS DEGREE
Federal Program Participation
What is your immediate educational goal?*

UndecidedHigh School DiplomaGEDCertificateAssociates DegreeBachelor’s Degree
College (s) Considering or Attending*

Colleges

1

2
College Major (s) Considering:*

Majors

1

2
Intended Career Field:
If unsure, please type "Undecided"
Have you participated in any of the following program since September 1st? (Check all that apply)*

Not ApplicableTRIO Student Support ServicesOther Federal ProgramsTRIO Upward BoundTRIO Talent SearchOther
College Admissions and Financial Aid
Have you completed a college admissions application for the school you plan to attend?*

YesNo
Have you completed a financial aid application (FAFSA) for the school you plan to attend?*

YesNo
EOC Services Needed
What services can EOC assist you with?*

FAFSA Application or other Financial Aid AssistanceAdmissions ApplicationsScholarshipsStudent Loan CounselingTesting Fee WaiverTranscript AssistanceCollege SearchTransfer AssistanceAcademic PlanningGED Guidance/ReferralCareer Exploration/PlanningFinancial Literacy/WellnessResume AssistancePersonal Counseling ReferralHousing/Food AssistanceRecently incarcerated/Returning Citizens - Referral Services
Dependency Status
If you cannot check any of the following boxes, you are considered a dependent student. Dependent students must provide parent financial information. *(please select all that apply to you)*

I am at least 24 years oldI am married or separatedI am a US Armed Forces Veteran or I am on Active DutyI have or will have children who I will provide more than half of their support for (other than support from parents) during the award year (July 1 ‐ June 30)I have dependents (other than a spouse or children) who live with me, and I will provide more than half of their support during the award year (July 1 ‐ June 30)I am currently or was an emancipated minorI was in foster care or a dependent or ward of the court since turning age 13I am currently, or I was in a legal guardianship (court‐ appointed to someone other than parents)Since I turned age 13, both of my parents were deceasedI am homeless or I am at risk of being homelessI have a special circumstance and I am not able to provide my parents informationNone of the above applies to me
Parent's Email Address*
example@example.com
Household Size
What is your current marital status?*

SingleMarriedDivorcedWidowedSeparated
Including yourself, how many people are supported by your income?*

1 person2 people3 people4 people5 people6 people7 people8+ people
Are there children under the age of 18 in your household?*

YesNo
Financial Information
Did you or will you file a 2023 Tax Return?*

YesNo
If yes, what was your (and your spouses) taxable income?*
(this can be found on IRS 1040 line 15 of your tax return)
If no, what how much did you (and your spouse) earn in wages/salary in the previous year?*
Authorization
I declare that the information on this form is true to the best of my knowledge. The Educational Opportunity Center at Texarkana College is authorized to access information deemed necessary to assist me in achieving my educational goals or in meeting the reporting requirements of the U.S. Department of Education, to record pertinent facts regarding my eligibility in the Program, services rendered, and placement. A copy of this statement shall serve as such authorization.
Signature of Applicant:*

Clear
Date*

MonthDayYear
mm-dd-yyyy

	Colleges
1
2

	Majors
1
2

Educational Opportunity Center at Texarkana College

Emergency Contact Information

Military Connected

Family Educational Background Information

Participant Educational Background

Federal Program Participation

College Admissions and Financial Aid

EOC Services Needed

Dependency Status

Household Size

Financial Information

Authorization