HEC TRIO EOC Intake Application

Needs Assessment Intake Application

The US Department of Education requires us to collect certain information from persons desiring to receive EOC services in order to determine their eligibility for FREE program services. All collected information is confidential.
NEEDS ASSESSMENT: What FREE Services Can We Provide for You? *

Financial Aid Application Completion (FAFSA) Scholarship Search/Application Completion Student Loan Consolidation/Repayment Options Defaulted Student Loan Remedies College Search/Application Assistance Career Coaching/Career Assessment HiSET/GED Tutoring Short-Term Training or Credentialing Programs Union/Trade School Information Resource referral (food, shelter, clothing, mental health, etc.) General Financial Literacy Training
NEEDS ASSESSMENT: Postsecondary Education & Financial Aid Assistance *

I have a desire to enroll in a program of postsecondary education (includes trade schools, short-term training and credentialing programs) I am enrolled in a program of postsecondary education (includes trade schools, short-term training and credentialing programs) I need information about how to apply for a program of postsecondary education (includes trade schools, short-term training and credentialing programs) I need assistance with applying for admission a program of postsecondary education (includes trade schools, short-term training and credentialing programs) I need information about financial aid I need assistance with applying for financial aid
Name *

First Name Middle Initial Last Name
Age Range *

14-18 years old 19-27 years old 28 years or older
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
Citizenship Status *

US Citizen Eligible Non-Citizen
English Is My Primary Language *

Yes No
Gender *

Male Female
Race and Ethnicity: *

Hispanic or Latino American Indian/Alaskan Native African American/Black Asian Caucasian/White Native Hawaiian/Other Pacific Islander Two or more races, non-Hispanic/Latino
Are You Military Connected? *

Not Applicable Veteran Spouse of Veteran Child of Veteran Active Duty Spouse of Active Duty Child of Active Duty
County of Residence *

Madison (IL) St. Clair (IL) Clinton (IL) St. Louis City St. Louis County Other
Cell Phone Number - If you don't have a cell phone, enter all zeros. *
Do You Want to Receive Periodic Text Messages From Us? *

Yes No
Alternate Phone Number - If you don't have an alternate phone, enter all zeros. *
E-mail Address - If you don't have an email address, enter NONE. *
Your Current Educational Status *

Need High School Diploma/GED/HiSET High School/GED/HiSET Graduate Not Enrolled in College (Trade School/Voc-Tech/2 yr/4 yr/Grad School) Enrolled in College (Trade School/Voc-Tech/2 yr/4 yr/Grad School)
Are You a 1st Generation College Student (Neither Biological/Adoptive Parent Has Received a 4-Year Bachelors Degree)? *

Yes No Unknown/Not Sure
Where Does Your TAXABLE Household Income Fit? *

$19,140 or less $19,141 - $25,859 $25,860 - $32,579 $32,580 - $39,299 $39,300 - $46,019 $46,020 - $52,739 $52,740 - $59,459 $59,460 - $66,179 $66,180 or more
Including Yourself, How Many People Are in Your Household? *

1 2 3 4 5 6 7 8+
Do You Currently Receive Services From Another Federally Funded Program? *

Not Applicable Upward Bound (UB) Upward Bound MathScience (UBMS) Veterans UB (VUB) Talent Search (TS) GEAR UP Student Support Services (SSS) Other Served by more than one federally funded program
How Did You Hear About Us? Check All That Apply. *

Family/Friend High School College: Lewis and Clark Community College College: Southwestern Illinois College College: St. Louis Community College-FP College: St. Louis Community College-FL College: Harris-Stowe State University College: Logan University College: Southern Illinois University Edwardsville Facebook Instagram YouTube Twitter LinkedIn Our website (hecstl.org) HEC TRIO EOC Outreach Event HEC TRIO Upward Bound HEC TRIO Educational Talent Search EOC Literature (flyer, brochure, business card, or mailer) Community Agency Government Program North County Tech/SSD Applied Health North County Tech Ultimate Cosmetology and Barber Academy
Have You Been Working with a Member of the EOC Team? If you're not sure, select any name. *

Antoinette Jones Debbie Burnett Diane Rainey Dorothy Smith Jimmy Harris LaMonica Parker Patricia Webb Paula Hampton Reman Jabar Christopher Thurmond Cassandra Pinkston
Participant Signature - I hereby certify that all of the information on this application is true and correct to the best of my knowledge. I understand that all of the information on this application is confidential and will be used for program recording, tracking, and reporting as required by the U.S. Department of Education. I give HEC TRIO Educational Opportunity Centers the right to reproduce, distribute, transmit, publish, display, in whole or in part, either digitally or in any other medium used my name and/or photographic image. I authorize HEC TRIO Educational Opportunity Center (HEC TRIO EOC) staff to verify my college, academic, enrollment, and financial aid information through National Student Clearinghouse, National Student Loan Data System, and other third-party entities. *

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Parent Signature Signature - Required if the applicant is not a veteran or is not married or does not have a dependent of their own or are under the age of 24. I hereby certify that all of the information on this application is true and correct to the best of my knowledge. I understand that all of the information on this application is confidential and will be used for program recording, tracking, and reporting as required by the U.S. Department of Education. I give HEC TRIO Educational Opportunity Centers the right to reproduce, distribute, transmit, publish, display, in whole or in part, either digitally or in any other medium used my name and/or photographic image. I authorize HEC TRIO Educational Opportunity Center (HEC TRIO EOC) staff to verify my college, academic, enrollment, and financial aid information through National Student Clearinghouse, National Student Loan Data System, and other third-party entities.

Clear
Date & Time of Submission *
Signature

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Signature

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Signature

Clear
Should be Empty:

Needs Assessment Intake Application