Brooklyn Educational Opportunity Center
Thank you for taking the time to complete this information.
STUDENT INFORMATION FORM
Please complete this form. Print all information clearly.
BEOC students receiving Temporary Aid to Needy Families (TANF) or SNAP may be eligible for
additional supportive services. To be considered for any of these services, please complete the
following questionnaire. A supplemental application may be required; if it’s determined that you
qualify for additional services.
Date: Banner/Student ID:
Last Name: First Name:
Program: Date of Birth:
Are any of the people living in your household (
Please check all that apply
):
A child under the age of 18
A pregnant woman
An adult who is not the parent, but is a relative caring for a minor child
You are the parent of a minor child that does not live with you, but you
are legally responsible for their financial support
OR
Are you receiving SNAP benefits only? Yes No
YOUR CURRENT BENEFITS (
check all that apply
)
Food Stamps WIC
Safety Net WIA
TANF recipient Social Security Disability
Other public assistance (specify)
None
Are you a veteran?
Yes No NA
Are you a single parent?
Yes No NA
Educational Level
(highest grade completed)
If English is not your 1
st
language, please indicate which is:
Please select one or more of the following racial categories to describe yourself:
American Indian or Alaska Native Asian
Black or African American White
Native Hawaiian or Pacific Islander
Do you consider yourself to be Hispanic/Latino? Yes No
Signature
The Brooklyn Educational Opportunity Center is requesting this information because often times we are
asked to describe the racial/ethnic backgrounds of our students and employees to help meet funding.
