Delta College-EOC-Intake Form

Educational Opportunity Center (EOC)

Participant Intake Form
Date*

MonthDayYear
mm-dd-yyyy
Name: *

First NameMiddle InitialLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone: *
(999)999-9999
Home Phone: *
(999)999-9999
Email: *
example@example.com
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Age:*

10-1314-1819-2728+
*All sections need to be filled out to determine eligibility for EOC services. All information on this form will be used for EOC purposes. Your personal information will be kept confidential.

Please complete with the most current and accurate information.
Please select:*

FemaleMale
Ethnic Background:*

American Indian or Alaskan Native, Non-Hispanic/LatinoAsian, Non-Hispanic LatinoBlack or African AmericanHispanic/Latino of any raceNative Hawaiian or other Pacific Islander, non-Hispanic/LatinoWhiteRace/Ethnicity unknownTwo or more races
Is English your primary language:*

YesNo
Are you a US citizen or legal resident?*

YesNo
Marital Status*

SingleMarriedDivorcedSeparatedWidowed
Were/are you a ward of the court, state or foster care at any time since age 13?*

YesNo
Military Connected*

Active Duty MilitarySpouse of Active Duty MilitaryChild of Active Duty MilitaryVeteranSpouse of VeteranChild of VeteranNone of the above
Do you have a documented disability?*

YesNo
If yes, please check all that apply:*

PhysicalLearningMedical
What is your total household size?*

123456789+
Taxable household income range last year:*

$21,870 or less$21,871-$29,579$29,580-$37,289$37,290-$44,999$45,000-$52,709$52,710-$60,419$60,420-$68,129$68,130-$75,839$75,840 +
Do you have any children or other dependents who rely on you financially:*

YesNo
Last year did your household receive?*

Cash AssistanceFood StampsSocial Security (SSI)Veteran BenefitsChild SupportOther
Did either of your parents receive a 4-year bachelor’s degree?*

YesNo
Are you currently in a GED or high school diploma program?*

YesNo
If yes, where? *
What is your highest level of education?*

9th grade10th grade11th grade12th gradeHS/GEDAdult w/out HS Cred (enrolled in ed program)Adult w/out HS Cred (not enrolled in ed program)HS DropoutContinuation/Alternate EducationVocational training/certificateAssociate’s DegreeBachelor’s DegreeMaster’s Degree
Grad Year: *
Did you drop out of college or a vocational school before receiving a degree or certificate:*

YesNo
Educational/Career goals:*
Have you applied for financial aid?*

YesNo
Services you would like to receive*

Academic AdvisingCareer Advising/InformationFinancial Aid (FAFSA)College SelectionCollege Admissions/ApplicationTransfer Planning/Campus VisitsAdult Education/GED CompletionJob TrainingReferral to Community AgenciesScholarship Information/SearchesOther
Who referred you to our program?*

School/Adult SchoolCareer Advising/InformationWalk-inFriend or Family MemberWorkshop/PresentationMailing/FlyerCommunity AgencyOther
Community Agency*
Please read each statement below, then sign and date.

I give permission to the Educational Opportunity Center program and staff to obtain, review, discuss and copy all records and information available through my previous schools (high school, college/university, etc.) including but not limited to academic records, financial aid records and to release information to the U.S. Department of Education and Delta College. All information obtained by the Educational Opportunity Center is completely personal and confidential and will only be used for verification of eligibility to this program.

The Educational Opportunity Center program and staff have my permission to communicate verbally, in writing, by email, or other means to share information with Delta College faculty, staff, departments, and/or off-campus professionals.

The Educational Opportunity Center program and staff have my permission to submit on an annual basis my name, date of birth, and social security number to the National Student Clearinghouse to verify enrollment and degree information

Being permitted to participate in activities and usage of equipment and facilities, I agree to indemnify and hold harmless the Educational Opportunity Center program and Delta College from any and all claims which are in any way connected with
such use or participation in the program.

I certify that all information provided on this intake form is true and complete.
Participant Signature: *

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Please click the link below to schedule a virtual or in-person appointment with an advisor.

https://outlook.office365.com/owa/calendar/EducationalOpportunityCenter@deltac.onmicrosoft.com/bookings/

Have Questions?

989-686-9470 – EOC@delta.edu – www.delta.edu/eoc

It is the policy of Delta College and the Educational Opportunity Center not to discriminate in employment, education, public accommodation or public service on the basis of religion, race, color, national origin, age, sex, marital status, sexual orientation, gender identity, height, weight, arrest record, veteran status, disability, or other classifications as required by applicable U.S. federal, state or local law. Direct inquiries to the Equity/Compliance Officer, Delta College, 1961 Delta Road, Equity Officer/Title IX Coordinator, Office J101, University Center, MI 48710, telephone 989-686-9247, or email: equityoffice@delta.edu. 18-276 (5/19)

TRiO EOC is funded through a grant from the U.S. Department of Education

Educational Opportunity Center (EOC)