Western Kentucky University-EOC-2024 Application Form

Name*

First NameMiddle InitialLast Name

Social Security Number or WKU ID or SKYCTC ID

Local Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County of residence:

Phone Number:

(999)999-9999

Email Address: *

example@example.com

Date of Birth:

Date

Gender:

Ethnicity: Are you Hispanic/Latino?

YesNo

If “No”, please select from below:

Is English your first language?

YesNo

U.S. Citizen?

YesNo

If Not a US Citizen, eligible non-citizen number

If not a US Citizen, Place of Birth

Please check if you are a (an):

Are you now or have you been:

HomelessIn or aging out of foster carein or aged out of guardianshipNone of the above

As of today, are you:

Are you providing more than 1/2 of the support for any children or other dependents (not including a spouse)?

YesNo

For how many dependents are you providing this support?

Total # in household

Please indicate your Family’s 2022 or 2023 taxable income from line 15 of the 1040:

Are you or anyone in your household receiving:

Did either parent receive a 4-year degree before you turned 18?

YesNo

What is your CURRENT educational status? (Choose ONE)

Completed 4-yr college degree Completed 2-yr degree or certificate Currently enrolled in College/Tech School* Dropped out of College or Tech School High School graduate GED graduate Currently enrolled in high school* Currently enrolled in a GED program* Did not complete high school and not enrolled in GED program

Where?

Year?

What grade were you in when you last attended school?

I Need Information On:

I Need Assistance With:

Completing Application(s) for AdmissionCompleting the FAFSAFiling Financial Aid AppealOther

I grant permission for my name/ photo to be released for advertising purposes.

YesNo

WKU’s EOC project is a USDE funded project which does not discriminate on the basis of age, color, national origin, sex, handicap, or religion, in admission policies, the administration and implementation of educational policies, employment, or any other activity.

I hereby authorize the exchange of information between the Educational Opportunity Centers (EOC) and other agencies, as necessary to assist me in achieving my educational goals. By signing and dating this application, I certify that, to the best of my knowledge, all information given is correct. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Signature

Today's Date

Date

Signature:

WKU Educational Opportunity Centers Application Form