Educational Opportunity Center intake form

Please don't fill out this input box.

Today's date*

First name*

Last name*

Address*

City*

State*

Zip*

Phone

Alternate phone

Email address

Personal Information

Date of birth*

Age*10-1314-1819-2728 and above

What is your gender?*FemaleMalePrefer not to answer

What is your ethic background?*American Indian or Alaskan Native Non-Hispanic LatinoAsian Non-Hispanic LatinoBlack or African American Non-Hispanic LatinoHispanic Latino of any raceNative Hawaiian or other Pacific Islander Non-Hispanic LatinoWhite Non-Hispanic LatinoTwo or more races Non-Hispanic LatinoRace or ethnicity unknown

Are you a U.S. Citizen or legal resident?*YesNo

Are you in active duty military*YesNo

Is your spouse in active duty military?*YesNo

Child in active duty military? *YesNo

Are you a veteran?*YesNo

Do you have a documented disability? *YesNo

If yes, please indicate the type of disability. PhysicalLearningMedical

Household Information

Do you have children or other people in your household that you support financially? *YesNo

Were you or are you a ward of the court or state or in foster care at any time since age 13?*YesNo

Are you homeless or at risk of being homeless? *YesNo

Educational Background

Did either of your parents receive a 4-year degree (Bachelor's degree)? *YesNo

If yes, which parent?MotherFather

If yes, do you live with that parent? YesNo

Are you currently in a GED or High School diploma program? *YesNo

If yes, where?

If you are a high school or GED graduate, what year did you receive your diploma?

Did you drop out of college or a vocational school before receiving a degree or certificate?*YesNo

Is English your primary language? *YesNo

What are your educational plans and career goals?*

Have you applied for financial aid for higher education?*YesNo

Are you currently being served by any of these programs?*Upward Bound-anyGEAR UPMichigan College and University Partnership Transfer Transition Program-MICUPOtherNone

Agreement & Signature

Please read each statement below, then sign and date.

I give permission to the Educational Opportunity Center program and staff to obtain, review, discuss and copy all records and information available through my previous schools (high school, college/university, etc.) including but not limited to academic records, financial aid records and to release information to the U.S. Department of Education and Delta College. All information obtained by the Educational Opportunity Center is completely personal and confidential and will only be used for verification of eligibility to this program.

The Educational Opportunity Center program and staff have my permission to communicate verbally, in writing, by email, or other means to share information with Delta College faculty, staff, departments and/or off-campus professionals.

The Educational Opportunity Center program and staff have my permission to submit on an annual basis my name, date of birth and social security number to the National Student Clearinghouse to verify enrollment and degree information.

Being permitted to participate in activities and usage of equipment and facilities, I agree to indemnify and hold harmless the Educational Opportunity Center program and Delta College from any and all claims which are in any way connected with such use or participation in the program.

By checking the box and typing my name below, I certify that all information provided on this form is true and complete.

I agree to the statement above.*I agree

Participant signature*

Today's date*

Educational Opportunity Center intake form

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