Danville Community College-EOC-Intake Form

Name:*

First NameMILast Name

Social Security Number

999-99-9999

Date of Birth*

mm-dd-yyyy

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell:*

(999)999-9999

Home:*

(999)999-9999

Please Select:*

Okay to TextNot Okay to Text

Email*

example@example.com

Please Select*

U.S. CitizenPerm ResidentOther

Number of people in the family/household: *

Number of your dependents:*

Are you Military connected?*

YesNo

Check all that applies:

VeteranActive Duty MilitaryChild of Active Duty MilitarySpouse of Active Duty Military

Marital Status:*

Are you Hispanic/ Latino?*

YesNo

Check all that applies:

Gender:*

MaleFemale

Age:*

Are you Proficient in English?*

YesNo

Does your Mother have a (4-year) bachelor’s degree?*

YesNo

Does your Father have a (4-year) bachelor’s degree?*

YesNo

Family/Household Taxable Income from IRS Form 1040, line 15:

$

Family/Household Taxable Income Range:*

Additional Sources of Income:*

Are you employed?*

YesNoDislocated

My intent is to enroll in:*

2-year CollegeVocational-Technical4-year University

Career of Interest: (If unsure, indicate Undecided)*

I need assistance with:*

Your Educational Status as of Today:

Studying for GED*

YesNo

GED Graduate*

YesNo

M/YR:

Enrolled in High School:*

YesNo

Grade:

High School Graduate:*

YesNo

M/YR:

Enrolled in College:*

YesNo

College:

College Graduate:*

YesNo

YR:

Degree:

College Stop-Out (More than 2 semesters since you were enrolled in college):*

YesNo

Are you currently participating in a TRIO Talent Search Program?*

YesNo

How did you hear about our TRIO Educational Opportunity Center?*

By signing this form, I understand that the above information is required by Federal Regulations to access the participant’s eligibility for TRIO EOC program services and to report statistics to the U.S. Department of Education. I give my permission for any other community service agencies and educational institutions to release my information to verify my income, educational, and financial aid status.

Applicant's Signature:*

Date*

mm-dd-yyyy

Parent’s Signature (Required for dependent applicants, under the age of 24 years old, unless exceptions apply)

The Southern Piedmont Educational Opportunity Center (EOC) is a federally TRIO Program administered by Danville Community College and was funded for $283,920.00 by the U.S. Department of Education (2024-25). The EOC is committed to Equal Opportunity. The EOC does not discriminate on the basis of gender, sexual orientation, race, color, political affiliation, national or ethnic origin, or disability in the administration of its policies, educational programs, or other administered services and activities. Danville Community College is an EEO/AA College. Updated 8/27/2024.

TRIO Southern Piedmont Educational Opportunity Center (EOC) 2024-25 Intake Form