Logo for Academic Achievement Programs, Office of Undergraduate Studies, University of Maryland

Educational Opportunity Center Program

STUDENT, PLEASE RESPOND TO ALL APPLICABLE QUESTIONS
Who is your assigned Counselor? *
Referred by: *
 
Last Name *
First Name *
Middle Name/ Initial
Address *
Address 2
City *
State *
Postal Code *
 
Home Phone
Cell/ Mobile Phone *
Office Phone
 
Email *
Date of Birth *
Gender *
What is your Family Size/ Household count?
Do either of your parents have a Bachelors Degree?
What is your Citizenship status? *
Ethnicity *
Do you have a Disability?
If you do have a disability, what kind of Disability do you have?
Physical
Emotional
Learning
Other
Do you have a problem reading or writing English?
Are you a Veteran?
School of Interest:
Four - Year College
Two - Year College
Vocational/Tech School
Undecided
Other

Name of School of Interest:
Career Goals:

Current School You Are In:
High School
Vocational
College
Unknown
Adult Not in School

What is your Current Grade Level: (If in High School, Vocational or College)
Are you currently participating in Talent Search?
Are you a High School Graduate?
Graduating Year: (If currently in High School)
Where are you enrolled? (If currently in High School)

Current Status: *
What Year did you receive your GED? (If you are a GED Graduate)
Do you need help with the following areas?
Admissions
Academic Support/Tutoring
Career Counseling
Financial Aid
GED
Financial Literacy
Other
What other help do you need? (If you selected Other from above)


INCOME VERIFICATION (COMPLETE USING YOUR TAXES)
How many person(s) comprise your household in the Current Tax Year 2023? *
What was your parent(s) annual income during the Current Tax Year 2023?
Did you file taxes separately from your parent(s) for the Current Tax Year 2023?
What was your annual income during the Current Tax Year 2023? (If you filed separately)
Income from Other Sources:
Income from Other Sources Annual Amount: $
What was your Taxable Yearly Income as stated on your Current Tax Year 2023? $ (Line 10 on IRS Form 1040)

I verify that the above information is correct and hereby authorize the UM-EOC to release and receive information to assist me with my education planning.
Applicant's Signature: (Please Sign) *
Please select a signature verification type.


Parent's Signature: (Please Sign if applicant is 18 yrs or less.)
Please select a signature verification type.

Enrollment Date: (mm/dd/yyyy)


The University of Maryland - Educational Opportunity Center (UM-EOC) is funded by the U.S. Department of Education and is committed to Equal Opportunity. UM-EOC does not discriminate on the basis of gender, sexual orientation, race, color, political affiliation, national or ethnic origin, or disability in the administration of its acceptance policies, educational programs or other administered services and activities.