EOC Initial Contact 2024.25

Educational Opportunity Centers of PA

EOC Program 2024.25
Name*

First NameLast Name
I am signing up for:*
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*
Ok to text?
What is your ethnicity*
Highest Grade Completed:*

Less than 10th11thI am a senior in High School (12th grade)12th/Graduated/GED CompletedBeyond High School1 year of college completed2 years of college completed3 years of college completedMore than 3 years of college but did not graduateCurrently enrolled in a GED ProgramI want to obtain a GEDI have a Bachelor Degree (4 Year)
Are you attending classes in post-secondary college or training now? If yes, please enter school name on next line:*

YesNoI want help to enroll
I am enrolled in this School: *
Not enrolled? Please put NA for Not Applicable
Military Connected:*
Are you receiving services from these other Dept of ED Funded Programs?:

Upward BoundGEAR UpVeteran Upward BoundTalent SearchStudent Support Services
Family's taxable income-using your tax return from last year:

Size of Family Unit with Income level up to that amount:
1 $23,475
2 $31,725
3 $39,975
4 $48,225
5 $56,475
6 $64,725
7 $72,975
8 $81,225
Each Additional Family Member $5,500
Is your family's taxable income above or below the income that corresponds to your family size above?*

Above the Income levelBelow the Income levelI am not sure-need help figuring it out
I am registering for (workshop or appointment)*
Did either of your parents receive a 4-Year Bachelor Degree? *
Does Anyone in your family receive the following?

TANFGeneral AssistanceSNAP (food stamps)Social SecuritySocial Security DisabilitySupplemental Social SecurityUnemployment CompensationMedical AssistanceWorkers CompensationChild SupportWICSchool Lunch Program
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*

Clear
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*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Educational Opportunity Centers of PA