Wahupa Educational Enterprises, Inc.-EOC-Application Form

What school do you currently attend?

Name:

First NameMILast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date

mm-dd-yyyy

Sex:

Social Security Number:

999-99-9999

Email:

example@example.com

Home Number:

(999)999-9999

Cell Number:

(999)999-9999

I authorize text messages for the cell phone number above, and accept responsibility for any charges that result

What is your highest level of education completed?

Are you currently enrolled in any classes? (Check all that apply)

if so, what college and/or courses?

Is English your second language and do you have difficulty speaking, reading, writing or understanding English?

Are you a:

Are you Hispanic/Latino?

Ethnic Background. Please select your race:

Are you:

If you are 24 years of age or older, please mark "N/A" to the following questions. If you are 23 years of age or younger, please check YES or NO to the following questions:

Rows	Yes	No	N/A
A) Are both of your biological parents deceased?
B) Do you have children or dependents who receive more than half of their support from you?
C) Are you currently serving in the U.S. Armed Forces (military)?
D) Are you or were you an emancipated minor or in legal guardianship as determined by the court?
E) Are you homeless or at risk of being homeless?
F) Did you graduate from a four-year university and will you attend graduate school this year?
G) Are you or were you a foster child/ward of the court?

If you answered NO to all of the above questions, please submit a “Parent Supplement Form”

Military Status. Please check the appropriate box

Did your parent(s) (natural or adopted) graduate with a bachelor’s degree from a four-year university?

What was your (and your spouse’s) taxable income last year (Jan.-Dec.)?

Number in household (including yourself, spouse, and children)

How can we help you with your educational needs? (Check all that apply)

I consent to the release of my name and photographs/videos in which I appear for educational, promotional and/or other program related purposes

I understand that the information provided above is kept strictly confidential and is used to establish eligibility for free TRIO/EOC services. I authorize the National Student Clearing house to release my post-secondary enrollment information, with and without a Social Security number. I authorize my counselor to obtain information regarding my secondary/post-secondary enrollment and financial aid status. I agree that my awareness of financial aid and postsecondary information is limited, and I can benefit from EOC services. I am currently not participating in any other TRIO programs. I certify that all my responses are correct to the best of my knowledge.

Signature

Date

COLLEGE & CAREER COUNSELING SERVICES INTAKE