Educational Opportunity Center Application

1. Applicant contact information

First name  

Middle initial

Last name  

Maiden name Maiden or other last name used

Mailing address  

Mailing address 2 Optional second line for the mailing address

City  

State  

Zip code  

Phone  

Email address

Birth date  

Year -- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Gender  

Male
Female

How did you hear about us?

My employer
My high school counselor
College/career fair
Community agency
Friend/family
Other

2. Military

Military service  

None
Active Duty
Veteran/Reservist
Spouse of Active Duty
Child of Active Duty

3. Citizenship

Citizenship status  

U.S. Citizen
Permanent Resident Alien
Intend on becoming a U.S. Citizen/Permanent Resident
Other

4. Ethnicity/Race

Are you Hispanic or Latino?  

Yes
No

Select all that apply

American Indian/Alaskan Native

Asian

Black/African American

White/Caucasian

Native Hawaiian/Pacific Islander

Primary language   What is the primary language you speak at home?

5. Highest degree earned

Highest degree earned   Please indicate the highest degree you have obtained

None
High school diploma/GED
Currently enrolled in College/Technical school
Some college
Associate's degree
Bachelor's degree
Graduate degree

Are you currently attending high school?

Yes
No

High school Please indicate which high school you are attending

Helen Thackston Charter School
York County School of Technology
Reading Senior High School
Other

6. Family education history

Has your mother received a 4-year degree?  

Yes
No

Has your father received a 4-year degree?  

Yes
No

Whom did you reside with until 18 years old?   With whom did you regularly reside with and receive support from until you were 18 years old?

Both father & mother
Mother only
Father only
Foster care
Homeless
Other

7. Income

Household members   What is the total number of persons (including you) in your household?

Your household's taxable income amount can be found on the federal income tax return.

• On IRS Form 1040, see line 43
• On IRS Form 1040A, see line 27
• On IRS Form 1040EZ, see line 6

Taxable income  

My household had taxable income from the last calendar year
My household had taxable income from the last calendar year (Please have a counselor call me as I have questions/need assistance)
My household had no taxable income during the last calendar year as all income was from non-taxable sources (i.e, AFDC, Disability, SSI, Unemployment, or Veteran benefits)

Taxable income amount My household's taxable (not total) income from the last calendar year was:

Note: If you are under the age of 18, guardian income information will be needed. A staff member will assist you with this when appropriate.

8. Services

Please indicate any TRIO programs you currently participating in

Upward Bound

Upward Bound Math and Science

Veterans Upward Bound

Talent Search

GEAR UP

Student Support Services

Other

I would like services to aid in my completion of a High School Equivalency / GED  

Yes
No

Do you wish to enroll in education beyond grade 12?   This could be a college or a technical education institute

Yes
No

Authorization   I hereby authorize the release of all educational records--future and past--to the Penn State SEPA EOC with the understanding that all records will remain private within EOC and the Department of Education.

I agree
I disagree

Withdrawal understanding   I understand that should I drop classes or withdraw from any services in which I have participated through EOC, I may be placed on inactive status or withdrawn from the EOC program.

I understand and agree
I do not understand and/or disagree

Digital signature   Please type your name below to electronically sign this application and in doing so, you certify that all of the information you provided on this application is true and complete to the best of your knowledge.

Note: If you are under the age of 18, a guardian's signature authorizing your participation in this program will be needed. A staff member will assist you with this when appropriate.