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? CHECK ALL THAT APPLY.
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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. CHECK ALL THAT APPLY.
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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
I need help with my student loans
Name
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First Name
Middle Initial
Last Name
Age Range
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14-18 years old
19-27 years old
28 years or older
Zip Code
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
St. Louis City (MO)
St. Louis County (MO)
Madison County (IL)
St. Clair County (IL)
Clinton County (IL)
Other Illinois County
Other Missouri County
Date of Birth
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-
Month
-
Day
Year
Date
Social Security Number
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Citizenship Status
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US Citizen
Eligible Non-Citizen
Other
If You are an Eligible Non-Citizen, Please Upload a Copy of your Permanent Resident Card, Resident Alien Card, or Alien Registration Receipt Card, I-94 Form or T-Visa
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English Is My Primary Language
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Yes
No
Gender Assigned at Birth
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Male
Female
Prefer Not to Say
Race and Ethnicity. CHECK ALL THAT APPLY.:
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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
How Are You Military Connected?
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Not Applicable
Veteran
Spouse of Veteran
Child of Veteran
Active Duty
Spouse of Active Duty
Child of Active Duty
County of Residence
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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.
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Do You Want to Receive Periodic Text Messages From Us?
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Yes
No
Alternate Phone Number - If you don't have an alternate phone, enter all zeros.
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What Is Best Time to Reach You? CHECK ALL THAT APPLY.
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Mornings (8:00 am - 11:59 am)
Afternoons (12:00 pm - 4:59 pm)
Evenings (5:00 pm - 7:00 pm)
Saturday Mornings
Saturday Afternoons
Saturday Evenings
E-mail Address - If you don't have an email address, enter NONE.
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Your Current Educational Status
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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)?
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Yes
No
Unknown/Not Sure
Where Does Your TAXABLE Household Income Fit?
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$21,870 or less
$21,871 - $29,579
$29,580 - $37,289
$37,290 - $44,999
$45,000 - $52,709
$52,710 - $60,419
$60,420 - $68,129
$68,130 - $75,839
$75,840 or more
Including Yourself, How Many People Are in Your Household?
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1
2
3
4
5
6
7
8+
Do You Currently Receive Services From Another Federally Funded Program?CHECK ALL THAT APPLY.
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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.
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Family/Friend
High School
Facebook/Instagram/Twitter/LinkedIn
YouTube Video
Our website (hecstl.org)
HEC TRIO Upward Bound
HEC TRIO Educational Talent Search
EOC Literature (flyer, brochure, business card, or mailer)
Community Agency
Government Program
iHeart Radio
Billboard
Urban Strategies
HSSU TRIO Upward Bound
HSSU TRIO Educational Talent Search
Urban Strategies Inc. (USI)
Special School District (SSD)
Have You Been Working with a Member of the EOC Team? If you're not sure, select any name.
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Antoinette Jones
Debbie Burnett
Diane Rainey
Dorothy Smith
LaMonica Parker
Patricia Webb
Paula Hampton
Reman Jabar
Marlana Hairston
Evelyn Madrid
Not Sure/No One
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 - 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.
For Dependent Students - Parent Name:
First Name
Last Name
For Dependent Students - Parent Contact Phone:
-
Area Code
Phone Number
For Dependent Students - Parent Email:
example@example.com
Date & Time of Submission
*
Signature
Signature
Signature
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Submit
Submit
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