EOC Initial Contact form 2020-21

Educational Opportunity Centers of PA

EOC Program 2020-21
Name *

First Name Last Name
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

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Ok to text?
What is your ethnicity *
Highest Grade Completed: *

Less than 10th 11th I am a senior in High School (12th grade) 12th/Graduated/GED Completed Beyond High School 1 year of college completed 2 years of college completed 3 years of college completed More than 3 years of college but did not graduate Currently enrolled in a GED Program I want to obtain a GED I have a Bachelor Degree (4 Year)
Are you attending classes in post-secondary college or training now? If yes, please enter school name: *

No Yes
Military Connected: *
Are you receiving services from these other Dept of ED Funded Programs?:

Upward Bound GEAR Up Veteran Upward Bound Talent Search Student Support Services
Family's taxable income-using your tax return from last year:

Family size:

1-$19,140

2-25,860

3-32,580

4-39,300

5-46,020

6-52,740

7-$66,180
Is your family's taxable income above or below the income that corresponds to your family size above? *

Above the Income level Below the Income level I am not sure-need help figuring it out
Did either of your parents receive a 4-Year Bachelor Degree? *
Does Anyone in your family receive the following?

TANF General Assistance SNAP (food stamps) Social Security Social Security Disability Supplemental Social Security Unemployment Compensation Medical Assistance Workers Compensation Child Support WIC School Lunch Program
Why do you need our services? *
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 *

Month Day Year
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 *

Month Day Year
Date
Should be Empty:

Educational Opportunity Centers of PA