Educational Opportunity Center

Participant Information

Last Name:

First Name:

MI:

Social Security # (no dashes):

Date of Birth (MM/DD/YYYY):

Current Age:

City:

State:

Zip Code:

Cell Phone:

Alternate Phone:

First-Generation Status:
Do either of your natural or adoptive parents have a 4-year bachelor’s degree (in the case where an individual regularly resided with and received support from only one parent, did that parent receive a bachelor's degree)?
Yes No

Have you received services (since September 1) from any of the following TRIO programs? (check all that apply):
Educational Opportunity Center Upward Bound/Upward Bound Math and Science Talent Search Student Support Services

Gender:
Female Male Nonbinary Prefer not to answer

Ethnicity:
Hispanic/Latino Not Hispanic or Latino

Citizenship:
U.S. Citizen Permanent Resident

(You will be asked to provide a copy of your Permanent Resident Card)

Race:
American Indian/Alaskan Asian Black/African American Native Hawaiian or Other Pacific Islander Caucasian/White Other

Do you give EOC permission to send texts to your cell phone?
Yes No

Military Connection

Veteran

Active Duty

Spouse of

Child of

Request for Services

Academic Advising

College Admissions

Financial Aid/Loans/Scholarships

Career Exploration/Planning

Veteran Services

GED/Highschool

Financial Literacy

Other

Dependency Status

Born before January 1, 2001

Currently Married or Separated

Have Children/Other Dependents

Parents deceased/Foster Care/Ward

Veteran or Armed Forces

Emancipated Minor/Legal Guardianship

Determined by liaison or Director to be an Unaccompanied Youth/Homeless

If "None" apply, you are considered "Dependent" and a parent must complete a parent income verification form. Please provide parent email address where the form can be sent:

Yes, I filed a 2023 Federal Income tax return

Filing Status:

Single

Head of Household

Married filing jointly

Married Filing Separately

Qualifying Widow(er)

Enter your Adjusted Gross Income (Tax Form 1040 Line 11):

Number of family members supported by this income:

Enter your Taxable Income: (Tax Form 1040 Line 15):

If unknown, check the amount below that best matches your Taxable Income:

$0 – 22,590

$22,591 – 30,660

$30,661 – 38,730

$38,731 – 46,800

$46,801 – 54.870

$54,871 – 62,940

$62,941 – 71,010

$71,011 – 79,080

Over $79,080

No, I did not file a 2023 Federal Income Tax return

Check all sources of income earned or received in 2023 AND provide a Total Amount earned or received from January 2023 - December 2023 (from all income sources) and the number family members supported by this amount:

Wages/Salary

Spouse, Partner, or Parent

Unemployment

Public Assistance

SSI/SSDI

Other/Financial Aid Source

Total earned/received from all the sources:

Number of family members supported by this amount:

To the best of my knowledge, the information that I have provided is true, complete, and accurate. As an EOC participant, I will be provided with services that will help me plan and complete my educational and career goals. I agree to work with the EOC to pursue these goals. I authorize the EOC program to release any information contained on this form to any other agency, school, or person that may require such information in order to assist me in completing my goals. I also authorize any public school, educational program and/or postsecondary institution that I have attended to release to Colorado State University EOC, upon their request, information pertaining to my academic, enrollment, and financial assistance record. I also give my permission for the use of my name and/or photograph for editorial promotional, recruitment, or education purposes.

I consent to use the electronic signature below to sign this document and acknowledge that the signature on this document is the legal equivalent of my manual/handwritten signature.

Full name (type your full name): required>

Signature Date:

SignCode (last 4 digits of your SSN):

Colorado State University