Big Bend Community College-EOC-Intake Form

Big Bend Community College EOC Intake Form
CONTACT & DEMOGRAPHIC INFO
Name*

First NameLast Name
Where did you attend or are currently attending high school?*
Date of Birth:*

MonthDayYear
mm-dd-yyyy
SSN:
CTCLink ID:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Phone:*
(999)999-9999
Gender:*

MaleFemale
Marital Status:*

SingleDivorced/WidowedMarried/Remarried
Legal Status:*

US CitizenPermanent ResidentOther
Ethnicity:*

White/CaucasianHispanic/LatinoNative American/Alaskan NativeAsianAfrican AmericanNative Hawaiian/Pacific Islander
Did your mother, father or adoptive parent earn a four-year college degree?*

YesNo
Are you active-duty or a veteran of the US Armed Forces?*

YesNo
Are you the spouse, child or dependent of a US veteran?*

YesNo
Do you have a documented learning disability? (response used for referrals)*

YesNo
What is your program of interest? *
EDUCATIONAL BACKGROUND
Are you currently enrolled in college or a vocational trade program?*

YesNo
Are you currently enrolled in high school or GED completion program?*

YesNo
Current educational level:*

HS Sophomore (10th)HS Junior (11th)HS Senior (12th)HS Diploma or GEDNo HS Diploma or GEDPS-Student (current)PS-Drop OutAssociate degree (AA)Bachelor Degree (BA/BS/BAS)
WHAT IS YOUR GROSS INCOME FROM THE LAST CALENDAR YEAR? If you’re a dependent student, please use your parent’s information for this section.*

No Income$20,385 or less$20,385--$27,465$27,466--$34,545$34,546--$41,625$41,626 -- $48,705$48,706 -- $55,785$56,745--$64,725$64,726 -- $72,975$72,976-- $81,225$81,226 and up
FILING STATUS:*

SingleMarried, filing SeparatelyMarried, filing jointly; qualifying widow/erHead of Household
HOUSEHOLD SIZE:*
Meeting Site: Where would you like to meet with a coordinator? *

Big Bend Community College CampusMoses Lake HSOthello HSOthello Work SourceQuincy HSQIARoyal HSWahluke HSWarden HSSoap Lake HSEphrata HSZoomOther
Check all the following services that would be helpful to you: (Select the ones that apply to you)*

Financial Aid Application (FASFA)Admissions ApplicationCollege SearchScholarship InformationOther
student signature*

Clear
Date*

MonthDayYear
Date
Information provided to the TRIO-EOC Program is confidential and will not be released without the student's permission.

By signing below, I authorize BBCC and the TRIO-EOC to request, receive, and release information to and from all applicable educational and career institutions to assist me in my educational planning, enrollment processes and verification, and securing financial aid and resources. I understand that my information may be released to the U.S. Department of Education for auditing and/or to request renewed funding. I verify that the information provided in this intake application is true and accurate to the best of my knowledge. (parent signature ALSO required for participants under 18)
If you are under 18, please have a parent or legal guardian sign in this box. If you are 18 or older, please sign again to confirm the statement above*

Clear
DATE:*

MonthDayYear
mm-dd-yyyy

Big Bend Community College EOC Intake Form

CONTACT & DEMOGRAPHIC INFO

EDUCATIONAL BACKGROUND