Fillable FillableMEOCPaperApplication112216

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FillableMEOCPaperApplication112216

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Country of origin: US
File type: PDF

U.S.A. forms for Columbia College (CA)

BROWSE COLUMBIA COLLEGE (CA) FORMS

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Motherlode Educational Opportunity Center (MEOC)
Participant Application
Student Information
First name: ______________________ MI: ______ Last name: ____________________
Phone #: ________________ Email: ________________________________________
Address: _______________________________________________________________
Social Security number: _ _ _ -_ _ - _ _ _ _ Date of birth: __ /__ / ____ Age: _____
Financial Information
Employment status: Full-time Part-time Unemployed
Income source: Welfare (TANF) Food Stamps (EBT) Social Security (SSI) Unemployment
Veteran benefits Other
_________________________
Number in household: ______
Do you have children under the age of 18 at home who you support? Yes No
Marital status: Single Married Divorced Widow
Last year, what was your “taxable” income?
Less than $17,820 $17,821 - $24,030 $24,031 - $30,240 $30,241 - $36,450
$36,451 - $42,660 $42,661 - $48,870 $48,871 - $55,095 $55,095 - $61,335 $61,336 +
High School / GED Information
Did you receive a high school diploma? Yes No GED? Yes No
Are you currently in a high school diploma program? Yes No
If yes, how many credits do you still need to graduate? ____________
Are you currently working on getting your GED? Yes No
If yes, how many tests have you passed? _____________
If you dropped out of high school, choose the highest grade completed.
Do you have the desire to pursue an education beyond high school? Yes No
College Information
Did you drop out of college? Yes No Do you have an AA/AS? Yes No
Did you drop out of vocational training? Yes No
Are you now attending college or a vocational training program? Yes No
What school are you currently attending? _____________________________________
Race/Ethnicity
Are you Hispanic/Latino? Yes No
Mark all that apply: American Indian or Alaska Native Asian Black or African American
White Native Hawaiian or other Pacific Islander
Background
Are you a U.S. citizen? Yes No If no, are you a legal resident? Yes No
Sex: Male Female Do you have difficulty speaking English? Yes No
Did either of your parents receive a 4-year Bachelor’s degree?
Yes No
If yes, did you live with them? Yes No
Other Information
Mark all that apply:
Homeless
Disabled
Learning Disability
Veteran/Depende nt
Formerly in foster care/Ward of court
Active-duty militaryEx-offender
How did you hear about MEOC services? ___________________________________
Are you receiving services from any other community agencies? Yes No
If yes, please list them below:
__________________________________________________________________
Participant Needs Assessment
Mark all that apply:
Aged-out foster informationAcademic guidance
Career explorationTutoring
Study skillsDisabled Student Services
Financial Aid applicationsChoosing a school/college
Transfer assistanceHousing info
Diploma/GED programFinancial literacy
Admission application
Budget planning
Mental Health Services
Defaulted student loans
Health services
Scholarships
Veterans/dependent services
Vocational training programsJob search skills
For clients under 23 years of age
If you are under 23, please provide your parent(s) full name(s):
___________________________________ __________________________________
Authorization
I declare under penalty of perjury that the information on this form is true to the best of my knowledge. Pursuant
to 20 USA 1231a of the U.S. Department of Education, MEOC is authorized to access information deemed
necessary to assist me in achieving my educational goals or in meeting the reporting requirements of the U.S.
Department of Education, to record pertinent facts regarding my eligibility in the program, services rendered,
and post-secondary education enrollment. This information is protected by the Privacy Act, kept confidential
and not to be seen unless specifically authorized. A copy of this statement shall serve as such authorization.
By typing in your name, you are legally signing this document.
_____________________
__________________________________________
Signature
_______________________________________
Parent signature (for minors)
Date
___________________
Date
Version 11/22/16 msw/arw
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FillableMEOCPaperApplication112216

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Completed 18 April 2020

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