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 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*

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 aid
Name*

First NameMiddle InitialLast Name
Age Range*

14-18 years old19-27 years old28 years or older
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Date of Birth*

MonthDayYear
Date
Social Security Number*
Citizenship Status*

US CitizenEligible Non-Citizen
English Is My Primary Language*

YesNo
Gender Assigned at Birth*

MaleFemale
Race and Ethnicity:*

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

Not ApplicableVeteranSpouse of VeteranChild of VeteranActive DutySpouse of Active DutyChild 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?*

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

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 TAXABLE Household Income Fit?*

$20,385 or less$20,386 - $27,464$27,465 - $34,544$34,545 - $41,624$41,625 - $48,704$48,705 - $55,784$55,785 - $62,864$62,865 - $69,944$69,945 or more
Including Yourself, How Many People Are in Your Household?*

12345678+
Do You Currently Receive Services From Another Federally Funded Program?*

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 SchoolFacebook/Instagram/Twitter/LinkedInYouTube VideoOur website (hecstl.org)HEC TRIO Upward BoundHEC TRIO Educational Talent SearchEOC Literature (flyer, brochure, business card, or mailer)Community AgencyGovernment ProgramiHeart RadioBillboardUrban StrategiesHSSU TRIO Upward BoundHSSU TRIO Educational Talent SearchUrban Strategies Inc. (USI)
Have You Been Working with a Member of the EOC Team? If you're not sure, select any name.*

Antoinette JonesDebbie BurnettDiane RaineyDorothy SmithJimmy HarrisLaMonica ParkerPatricia WebbPaula HamptonReman JabarNaquittia Noah
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.

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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*
Signature

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Signature

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Needs Assessment Intake Application