Texarkana College-EOC-Continuing Intake Form

Educational Opportunity Center at Texarkana College

Continuing 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.
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
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
Household Size
What is your current marital status?*

SingleMarriedDivorcedWidowedSeparated
Are there children under the age of 18 in your household?*

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

Enrolled in high school (12th grade)Did not finish high school – Not Enrolled ina 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?*

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 otherFinancial AidAdmissions ApplicationsScholarshipsStudent Loan CounselingTesting Fee WaiverTranscript AssistanceCollege SearchTransfer AssistanceAcademic PlanningGED Guidance/ReferralCareer Exploration/PlanningFinancial Literacy/WellnessResume AssistancePersonal Counseling ReferralHousing/Food AssistanceRecently incarcerated/ReturningCitizens - Referral Services
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

Household Size

Participant Educational Background

Federal Program Participation

College Admissions and Financial Aid

EOC Services Needed

Authorization