Educational Opportunity Center Program Application
Site:
2755 E. Napier Avenue Benton Harbor, MI 49022 269-927-8100 Toll-free: 800-252-1562 Fax
269-927-8175 The Educational Opportunity Center is funded by a US Department of Education grant
DEMOGRAPHIC DATA (Please Print)
Director
Application Date
Name:
Last
First
Middle I
nitial
Address:
Street
State
County
City
Zip
Permanent Address:
Street
City
Cell Phone
State Zip
County
Home Phone
Email Address
*Social Security #:
*required for EOC services
Date of Birth: Age
Place of Birth:
(City, State, Country)
GENDER:
Female
Male
MARITAL STATUS:
Single with (Children) Dependents/head of household
Single
Married Date:
Divorced Date:
Separated Date:
Widowed Date:
ELIGIBILITY
INFORMATION:
Emp
loyed
Unemplo
yed
Disable
d
Public Assistance
Social
Sec
urity (SSI)
Incarce
rated
Release Da
te:
DOC #:
BACKGROUND:
Mother has a 4 year
college degr
ee
YES
NO
2/10/2020 kw
Father h
as a 4 y
ear college degree
YES NO
RESIDENCY STATUS:
Citizen of the US
US Naturalized
(obtained Citizenship)
Legal Resident
(green card, visa, etc.: Documentation Required)
other
(Documentation Required)
MILITARY STATUS:
Veteran
Active duty
Registered with Selective Service Board
(Male 18 and older)
unknown
Are you the spouse or a child of an active
duty military person?
SPOUSE CHILD
Not applicable
FAMILY SIZE
(# you claim)
2020 FEDERAL LOW
INCOME GUIDELINES
1
$19,140
2
$25,860
3
$32,580
4
$39,300
5
$46,020
6
$52,720
7
$59,460
8
$66,180
Please Check: I hereby certify, under penalty of
perjury, that my taxable income
Does Does Not
Exceed the levels listed above on the size of my
family unit.
EDUCATIONAL STATUS
(Check all that apply):
HS Senior:
School Attendi
ng:
Currently in a GED/HS Program School
HS Drop Out: Last Year Grade Attended
HS Graduate: School Year Graduated City/State
GED Program Graduate Year graduated
Vocational/Technical Certificate Program of Study: Year graduated:
Some College: School: Dates Attended:
College Graduate 2-year 4-year Year graduated:
EDUCATIONAL ASSISTANCE NEEDED
(Check all that apply):
GED information
GED/Assessment tutoring
Financial Literacy
Financial Aid/FAFSA
Financial Aid Appeals
Scholarships/other aid options
Transcript request High School/GED/College
College applications
College exploration
College placement exams/tutoring
Career options/information
Academic Advising
Veteran Services
Other
Educational Goal: Earn GED/HSD Earn Vo/Tech Certificate Earn Associates/Bachelor’s Degree Other
Career Interest:
Examples: Business/HVAC/CAD/Dentistry/Nursing
Are you CURRENTLY participating in a TRIO Program? (*
PLEASE CHECK ALL THOSE THAT APPLY
).
No Yes if yes indicate which one: Upward Bound Upward Bound Math-Science Veterans Upward bound
Talent Search GEAR UP Student Support Services Other
If Yes when and where?
STATEMENT OF RELEASE OF INFORMATION AND CONFIDENTIALITY
I understand that to be admitted to the EOC program, I must provide my Social Security number.
I hereby consent the release of my post-secondary information to the EOC program at Lake Michigan College, effective for the period
of time that I am an active EOC participant and receive EOC services.
I affirm that my reported income does or does not exceed the levels listed in the Eligibility/Income section of the application.
I understand that the Educational Opportunity Center is a federally-funded program, this application is subject to review by Federal
authorities, and I will be held responsible for the certifications made by my signature.
I affirm all information provided on this application is true and accurate to the best of my knowledge.
*Applicant Printed Name:
*Applicant Signature: Date:
*If you are a dependent student, this form needs to be completed and signed by your parent/guardian who claims you for federal
income tax purposes.
*Parent Signature: Date:
_____________________________________________________________________________________________________________
FOR OFFICE USE ONLY
Site _______________________________ Date Application Received _________________ EOC Staff Initials_________
Eligibility __LI __FG Date Application Processed ________________ EOC Staff Initials_________
Comments:
Lake Michigan College Educational Opportunity Center
Ethnicity/Race Questionnaire (Supplement to EOC Application)
Please read and respond to the questions. Definitions are provided to clarify each category.
Question 1:
Are you, the applicant, Hispanic/Latino?
Check only one: Yes No
Question 2:
To which racial group(s) do you belong?
Check all that apply: (see definitions to right)
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Definitions (as determined by the U.S Department of Education)
Hispanic/Latino: A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish Culture or origin, regardless to
race.
American Indian or Alaska Native: A person having origins in any of
the original peoples of North and South American (including Central
America and who maintains a tribal affiliation or community
attachment.
Asian: A person having origins in any of the original peoples of the Far
East, Southeast Asian, or the Indian subcontinent including, for
example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
Black or African-American: A person having origins in any of the Black
racial groups of Africa
Native Hawaiian or Other Pacific Islander: A person having origin in
any of the original peoples of Hawaii, Gran, Samoa, or Pacific Islands.
White: A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa
Name (Printed) Signature Date
2/10/2020 kw
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome