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Homepage > TRiO

Educational Opportunity Center Intake Form

Last Name:

First Name:

Middle Initial:

Phone:

Email:

SSN:

Date of Birth:

Gender:

Address:

City:

State:

ZIP:

Citizenship (check all that apply):

                    

Ethnicity (check all that apply):

How many people live in your home, including you?

What was your household income last year?

Please select your highest completed education level:

Are you currently enrolled in GED/ABE Classes, High School or Alternative Education?

Are you currently enrolled in any College, Career Tech or Vocational School?

Did either of your parents earn a 4-year degree?

Are you interested in furthering your education?

Are you a prior TRiO participant?

EOC Specialist that directed you to the site for intake completion:

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Confidential Records Release

The Educational Opportunity Center (EOC) administration at Rogers State University (RSU) is hereby granted permission to request and receive student educational records for post-secondary education retention and graduation tracking purposes. These will be limited to the following:

• official school transcripts with test scores
• test results, if available (PSAT, SAT, ACT, PLAN, etc.)
• basic skills test results
• student history file/academic report with test scores
• enrollment information from the National Student Clearinghouse

Permission is also given to post-secondary institutions (universities, colleges, proprietary schools, technichal schools) and/or educational or other agencies to release to EOC at RSU any information or documentation for educational tracking purposes related to the student's:

• admissions
• enrollment
• financial aid
• academics (i.e. transcripts)

Once signed and dated this release will be valid throughout the student's educational career and as long as EOC has need for the information. It is understood that this information will be handled in a confidential manner and will only be available to EOC program staff and representatives of Federal and State Departments of Education.

I certify that the information on this form is acurate and complete to the best of my knowldege. Permisson is granted to RSU and EOC to use information and/or photographs about the student for use in media relases, publications, brochures, newsletters, advertisements, social media and other promotional uses without notifying the client or legal guardian. RSU is held harmless of any liability.

I agree to the above Confidential Records Release.

Client Signature

Date

Parent Signature

Date

Please Note: A parent or guardian signature is required if the client is under 18. If the client is over 18, please sign your name again in the parent signature field. 

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Office Use Only

RSU EOC is in compliance with TItle IV of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 and Sec. 503 & 504 of the Rehabilitation Act of 1973. RSU EOC does not discriminate on the basis of race, color, national origin, sex or handicapped status in any of its policies, practices or procedures. This includes but is not limited to admissions, employment, financial and educational services.

EOC Educational Specialist Signature:  

Date:

Staff Only Verification Check:

Determination: