* indicates a required field
| Which workshop are you registering for? * | |
| Expected High School Graduation date, if applicable. (dd/mm/yyyy) | |
| Last name: * | |
| First name: * | |
| Middle initial: | |
| E-mail address: | |
| Address: * | |
| City * | |
| State * | |
| Zip * | |
| Phone number: * | |
| Gender: * | |
| Year of birth: * | |
| Age: * | |
| U.S. citizen or permanent resident? * | |
| Veteran? * | |
| Ethnicity: * | |
| Educational status: * | |
| I am interested in obtaining information and/or assistance regarding: * | |
| If other, please indicate: | |
| Have either of your parents completed a bachelor's degree (4-yr. degree)? * | |
| Household size (including self): * | |
| Household income last year: | |
| Source of monthly income: * | |
| If other, please indicate: | |
| How did you hear of our services? * | |
| If other, please indicate: | |
| I authorize the exchange of information between the Educational Opportunity Center (EOC) and other agencies, as necessary to assist me in achieving my educational goals. I certify that the information provided is complete and correct in every respect. * | |
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