EOC Initial Contact form 2021-22.a.

Educational Opportunity Centers of PA

EOC Program 2021.22
Name*

First NameLast 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

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone 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:*

NoYesOther
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:

Family size:

1-$19,320

2-$26,130

3-$32,940

4-$39,750

5-$46,560

6-$53,370

7-$60,180

8-$66,990

For familes with more than 8 members, add the following amount for each additional family member: $6,810.
I am registering for:
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
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
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*

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