Highland Community College-Freeport-EOC-Application Form-Joseph

Today's Date:*

mm-dd-yyyy

Name:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number:*

(999)999-9999

Email Address:*

example@example.com

I would like to receive text messages regarding my appointments, deadlines, scholarships, and any other necessary communication.*

YesNo

Date of Birth:*

mm-dd-yyyy

Age:*

Gender:*

MaleFemaleOther

Race (select all that apply):*

Status:*

US CitizenPermanent ResidentOther

Are you a Veteran?*

YesNo

Marital Status:*

MarriedSingle

Do you have children under 18?*

YesNo

Did either one of your parents graduate from college with a 4-year degree?*

YesNo

Number in Household*

What is your taxable income?

Taxable income is not the same as gross or adjusted gross income. Look at the following line on your taxes for last year: Form 1040- line 15. If you did not file taxes your taxable income is $0. Please note: If you are filling this out and UNDER 24 and have NOT been declared independent an additional income form will need to be completed by your parent or guardian.

Please indicate how you heard about EOC:*

HCC staff member:

Are you currently enrolled in another TRIO program?*

YesNo

If yes, which program?

Are you disabled?*

YesNo

What are your immediate educational goals?*

Please check your current educational status:*

Grade

9th10th11th

Check all the following services that would be helpful to you.*

Certification:*

I certify that the information I have reported is accurate to the best of my knowledge.

Applicant Signature:*

Date:*

mm-dd-yyyy

EOC Interest Form