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Student Information
First Name *
Last Name *
Middle Name
Date of Birth *
Age *
State *
Local Address *
City *
Zip *
County
Contact Phone *
Email Address *
Gender *
Social Security Number
Ethnicity *
If you identify as more than one ethnicity, please indicate here
Communication preference: Phone, text, email. List all that apply
How did you hear about MEOC?
Are you comfortable reading and writing English? *
Are you a US citizen or legal permanent resident? *
Please indicate the status of citizenship *
Please mark yes or no for any special circumstances that apply to you.
Disabled (physical, emotional, emotional)
Learning Disability (IEP or 504 plan in high school, other LD diagnosis
Currently Incarcerated
Formerly Incarcerated
Currently experiencing homelessness
Current or former Foster Youth (received Foster Care services at some point before age 18)
Veteran/Active Duty Armed Services member or family member living with a Veteran or Active Duty Armed Services

Financial Information: (If under 24 and considered a dependent for FAFSA, this should include your parents income information)
Household Size *
Income Bracket *
Have you been declared an independent student? (Same as FAFSA) *

Academic Information: Please fill out all information in both bolded sections that applies to you. Leave blank if not applicable.

High School Information

High School status as of this application:
If still in High School, which high school are you currently attending?
If still in High School, what is your expected graduation date?
Do you want to attend college or vocational school? *

College Information

College status as of this application:
College you are currently attending:
Intended college graduation date:
Have either of your parents (that you were raised with) completed a bachelors degree? *

-Participant Needs Assessment-

Academic needs

  • Academic Guidance
  • Admissions Application
  • Vocational Training

List all that apply in the box below:

Financial Needs

  • Budget Planning
  • Financial Literacy
  • Financial Aid

List all that apply in the box below:

Personal Needs

  • Career Exploration
  • Housing Information
  • Mental Health
  • Veteran Services

List all that apply in the box below:


*Additional Information: Specialized Services Requests (Optional) Ex: You can list what type of school you want to attend, or what you would like to study. Please provide that information in the box listed below.

Authorization: I declare under penalty of perjury that the information on this form is true to the best of my knowledge. Pursuant to the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99), 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, verification of secondary education completion 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
Participant Signature *
Please select a signature verification type.
Parent/Guardian Singature (for dependents under 24)
Please select a signature verification type.