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? CHECK ALL THAT APPLY.*

Financial Aid Application Completion (FAFSA)Scholarship Search/Application CompletionStudent Loan Consolidation/Repayment OptionsDefaulted Student Loan RemediesCollege Search/Application AssistanceCareer Coaching/Career AssessmentHiSET/GED TutoringShort-Term Training or Credentialing ProgramsUnion/Trade School InformationResource referral (food, shelter, clothing, mental health, etc.)General Financial Literacy Training
NEEDS ASSESSMENT: Postsecondary Education & Financial Aid Assistance. CHECK ALL THAT APPLY.*

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 aidI need assistance with applying for financial aidI need help with my student loans
Name*

First NameMiddle InitialLast Name
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Age Range*

14-18 years old19-27 years old28 years or older
County of Residence
Last 4 Digits of Social Security Number*
Citizenship Status*

US CitizenEligible Non-CitizenOther
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*

YesNo
Gender Assigned at Birth*

MaleFemale
Race and Ethnicity. CHECK ALL THAT APPLY.:*

Hispanic or LatinoAmerican Indian/Alaskan NativeAfrican American/BlackAsianCaucasian/WhiteNative Hawaiian/Other Pacific IslanderTwo or more races, non-Hispanic/Latino
How Are You Military Connected?
How Are You Military Connected?*

VeteranSpouse of VeteranChild of VeteranActive DutySpouse of Active DutyNot ApplicableChild of Active Duty
County of Residence*

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

YesNo
Alternate Phone Number - If you don't have an alternate phone, enter all zeros.*
What Is Best Time to Reach You? CHECK ALL THAT APPLY.

Mornings (8:00 am - 11:59 am)Afternoons (12:00 pm - 4:59 pm)Evenings (5:00 pm - 7:00 pm)Saturday MorningsSaturday AfternoonsSaturday Evenings
E-mail Address - If you don't have an email address, enter NONE.*
Your Current Educational Status. Check all that apply.*

Need High School Diploma/GED/HiSETHigh School/GED/HiSET GraduateNot 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)?*

YesNoUnknown/Not Sure
Where Does Your 2024 TAXABLE Household Income Fit?*

$23,475 or less$23,476 - $31,725$31,726- $39,975$39,976- $48,225$48,226 - $56,475$56,476 - $64,725$64,726 - $72,975$72,976 - $81,225$81,226 or more
Including Yourself, How Many People Are in Your Household?*

12345678+
Do You Currently Receive Services From Another Federally Funded Program?CHECK ALL THAT APPLY.*

Not ApplicableUpward Bound (UB)Upward Bound MathScience (UBMS)Veterans UB (VUB)Talent Search (TS)GEAR UPStudent Support Services (SSS)OtherServed by more than one federally funded program
How Did You Hear About Us? CHECK ALL THAT APPLY.*

Family/FriendHigh School/CollegeFacebook/Instagram/Twitter/LinkedInYouTube VideoOur website (hecstl.org)HEC TRIO Upward BoundHEC TRIO Educational Talent SearchEOC Literature (flyer, brochure or business card)Community Agency/OutreachGovernment ProgramUrban Strategies Inc. (USI)Foxy 106.9The ArgusKMOVPostcard MailerDEPARTMENT OF CORRECTIONS
Have You Been Working with a Member of the EOC Team? If you're not sure, select any name.*

Antoinette JonesDebbie BurnettDiane RaineyDorothy SmithLaMonica ParkerPaula HamptonEvelyn MadridWill SmithLauren LittleCassandra PinkstonUnsure/No One
Team Member Email
example@example.com
A. Jones
example@example.com
D. Burnett
example@example.com
D. Rainey
example@example.com
D. Smith
example@example.com
L. Parker
example@example.com
P. Hampton
example@example.com
E. Madrid
example@example.com
W. Smith
example@example.com
L. Little
example@example.com
C. Pinkston
example@example.com
M. Hairston
example@example.com
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.

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For Dependent Students - Parent Name:

First NameLast Name
For Dependent Students - Parent Contact Phone:

Area CodePhone Number
For Dependent Students - Parent Email:
example@example.com
Date & Time of Submission*
Paper Intake (Completed Front & Back)

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DOC Release Date/Follow-Up Date

MonthDayYear
Date
Should be Empty:

Needs Assessment Intake Application