2021-2022 LEOC Application Form

First, be sure to review the eligibility requirements. After that, complete this form to apply now! 

If you'd prefer, you can also download and print an application! We have an Adult Application and a High School Application.

* denotes a required field

Application Type


Personal Information




Ethnicity (Select all that apply.) *







Education Information

Educational Status (Select all that apply.) *









Contact Information




Needs Assessment

Needs Assessment (Select all that apply.)













Needs Assessment (Select all that apply.)
















Current TRIO Participation

I am currently a participant of the following: *



College/Career Goals

First Generation Status


Income Verification

Note: Individuals younger than 24 years of age not qualified as Independent must provide their parent or guardian’s tax information and signature. To qualify as independent, you must be at least one of the following: 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, or someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.



If no, please complete the information below as a verification of your family income from last year.  
If yes, please provide your own taxable income from last year.

*Taxable Income: This information is located on tax forms (1040-line 11b)
DO NOT USE YOUR ADJUSTED GROSS INCOME.


Independent Student Signature (If Dependent, Parents need to sign below.)

Independent Student Signature
(If Dependent, Parents need to sign below.)


The information requested on this form will be utilized to assist us in providing services for you or your student. To provide the most effective services, we may need to obtain information from several sources, such as high schools, colleges, testing agencies, counselors, admissions and financial aid officers, social workers, etc. ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT.

School Records

I grant the Laker Educational Opportunity Center (LEOC) Program permission to obtain school records, transcripts, standardized test scores (EOC/EOG/SAT/PSAT/ACT/PLAN) grade reports, test results, and financial aid transcripts from the secondary school and college I am attending until I graduate from college or for 6 years after I graduate from high school, according to the terms of the federal LEOC grant. I will also permit LEOC program staff to speak with teachers, counselors, and other school administrators to obtain and exchange information as part of the services I will receive from the LEOC program. I authorize LEOC to access or release copies of my academic transcripts, test scores, college admissions enrollment, and financial aid information that is necessary to assist in achieving my education goals.


Media Release

Periodically, students participating in the LEOC program events may be photographed, filmed, or interviewed. I grant permission to the LEOC staff to use my photographs, film or interviews that may be used to promote or publicize the program events or demonstrate how federal funds are utilized to assist students.


Applicant Signature
Applicant Signature *

I understand that the above information will be held strictly confidential and will be used for supporting my educational aspiration for college enrollment. All the information provided is true and complete to the best of my knowledge.


Parent/Supporter Signature (Required if applicant is under 18 years old)

I understand that the above information will be held strictly confidential and will be used for supporting my educational aspiration for college enrollment. All the information provided is true and complete to the best of my knowledge.


Human Verification *


Page last modified November 28, 2023
Report a problem with this page