Educational Opportunity Centers of PA Initial Contact Form

Educational Opportunity Centers of PA

EOC Program 2022-23
Name

First NameLast Name
Please enter your Date of Birth:
Month-Day-Year
Age
Gender
Are you a US Citizen or eligible non-citizen?
Permanent Resident-please be prepared to provide A#
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Ok to text?
What is your ethnicity
Highest Grade Completed:
Are you attending classes in post-secondary college or training now? If yes, please enter school name:

Other
Military Connected:
Are you receiving services from these other Dept of ED Funded Programs?:
Family's taxable income-using your tax return from last year:

Family size:

1-$21,870

2-29,580

3-37,290

4-45,000

5-52,710

6-60,420

7-$68,130

8-$75,840
Is your family's taxable income above or below the income that corresponds to your family size above?
Did either of your parents receive a 4-Year Bachelor Degree?
Does Anyone in your family receive the following?
Why do you need our services?
I certify that the information provided is correct. I give permission to Educational Opportunity Centers of PA to verify my enrollment in school and to use the information to assist in my educational planning or in reports that do not identify me by name.Signature
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE REQUIRED FOR DEPENDENT STUDENTS THAT ARE 24 YEARS OF AGE & UNDER. PLEASE WRITE N/A IF NOT APPLICABLE TO YOU. I certify that I am the parent/guardian of the participant and that the information provided is correct. I give permission to Educational Opportunity Centers of PA to verify school enrollment of my son/daughter and to use the information to assist in his/her's educational planning or in reports that do not identify by name. Signature
Date

MonthDayYear
Date
Should be Empty: