2024 Educational Opportunity Program (EOP) Application

I wish to matriculate in: *

I wish to matriculate in: Fall 2024 Spring 2024
Part I - Personal Data

Name Name * First Last

Gender *

Gender Male Female Unknown/NA Non Binary

Date of Birth Date of Birth * / MM / DD YYYY

Mailing Address Mailing Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

How long have you lived in Orange County, NY? *

How long have you lived in Orange County, NY? More than one year Less than one year

Phone Phone * - ### - ### ####

Personal Email *

Racial or Ethnic Group *

Racial or Ethnic Group Hispanic American Indian/Alaskan Native Black/African American Native Hawaiian/Pacific Islander White Race/Ethnicity Unknown

Did you participate in any of the following programs in high school (click all that apply)? *

Did you participate in any of the following programs in high school (click all that apply)? Upward Bound Talent Search Liberty Partnership Program Gear Up Early College None

Are you a citizen of the United States?

Are you a citizen of the United States? Yes No

Are you in Foster Care *

Are you in Foster Care Yes No

Are you a Ward of the State? *

Are you a Ward of the State? Yes No

Are you homeless?

Are you homeless? Yes No

Do you have reliable internet services?

Do you have reliable internet services? Yes No

Part II - Educational Data

Name of the high school you graduated from or expect to graduate from *

High School Average *

Date of high school graduation or anticipated graduation date Date of high school graduation or anticipated graduation date * / MM / DD YYYY

If you did not graduate from a NYS high school, did you receive a GED (General Educational Development Test)?

If you did not graduate from a NYS high school, did you receive a GED (General Educational Development Test)? Yes No

If yes, please provide the date If yes, please provide the date / MM / DD YYYY

Type of High School Diploma

Type of High School Diploma Regents Regents with advanced designation General IEP (Individualized Educational Program)

Are you a transfer student?

Are you a transfer student? Yes No

Were you previously enrolled in an opportunity program? *

Were you previously enrolled in an opportunity program? Yes No

If yes, which one?

If yes, which one? EOP HEOP SEEK College Discovery Other

Part III - Income Data

What was your household income for the 2022 year? *

Household Size for the 2022 Year (number of people in your home).

Does your family receive any of the following benefits listed below? (Please respond to the following questions by placing a check mark (√) in the answer box
that corresponds to your response). *

Does your family receive any of the following benefits listed below? (Please respond to the following questions by placing a check mark (√) in the answer box
that corresponds to your response). Unemployment Public Assistance Social Security Veterans Benefits SNAP Benefits Other

Please upload income for the 2022 year.

Attach Files

Part IV - Other

Please write a personal statement as to why you would like to join the Educational Opportunity Program *

Applicant's Signature (use mouse or touch pad to draw your signature) *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

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2024 Educational Opportunity Program (EOP) Application

2024 Educational Opportunity Program (EOP) Application

Part I - Personal Data

Part II - Educational Data

Part III - Income Data

Part IV - Other