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TRiO EOC Participation

(*Required Form Fields)
Personal Information
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For the period of Sept 2013 thru Aug 2014 only, have you participated in any of the following programs?

Ethnicity: Are you Hispanic/Latino?


Race:






Gender:


Are you a U.S. citizen? *


Did your birth or adoptive parent(s) that you resided with prior to age 18 earn a bachelor's degree? *


Are you proficient in English? *


Dependency Information

1. Military Connections: *
Are you a Veteran?
Are you active duty military?
Are you the spouse of an active duty military person?
Are you the child of an active duty military person?

2. Are you currently married or do you have children who receive more than half of their support from you? *


3. At any time since you turned age 13, were both your parents deceased, were you in foster care, or were you a dependent or ward of the court? *


4. Have you been documented as a homeless youth? *


5. How many individuals are supported by the household income (household size)? *

Income Information

6. Enter your household's taxable income (IRS 1040 line 43, IRS1040A line 27, IRS1040EZ line 6) for the previous year. *

7. Household funding sources (check all that apply) *
a) Wages/salary
b) Unemployment
c) TANF
d) SSI or SSDI
e) Social Security
f) Other

Education Information

8. If you are currently enrolled in a GED program, or plan to enroll, will you earn your GED by August 31st? *



9. If you have an Associateís Degree or Certificate, are you returning to achieve another certificate or degree? *



10. Is it your intent to go on to earn a bachelorís degree? *



11. What is your current education level? (check only one) *








12. Enter the name of your current or previous high school or postsecondary (college) institution: *

Goals, Personal Statement, and Needs Assessment

13. I am interested in enrolling in college. *

14. I desire to enroll in college to pursue a degree/career in:

15. because:

16. I would like more information about and/or assistance with:
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b)
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d)
e)
f)
If other:

I hereby certify that this information is correct to the best of my knowledge. By checking the box below, I am granting all TRiO EOC and college personnel access to the information contained on this form and in the RCC system for the purposes of program recording, tracking, and reporting as required by the U.S. Department of Education. I allow TRiO EOC personnel to conduct research pertaining to my educational outcomes as they relate to the TRiO EOC program using phone, email or other digital mediums.