TRIO Application

Name

• *First Name
• Middle Initial
• *Last Name

Other Information

• *Student ID
• *Gender
  
  Female
  Male
  
  
• *Birth Date

Current Address

• *Street/PO Box/Apt #
• *City
• *State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY *Zip/Postal Code

Permanent Address (if different)

• Street/PO Box/Apt #
• City
• State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip/Postal Code

Phone and Email

• *Mobile Phone
• Secondary Phone
• *EICC Email address
• Personal Email address

Contact Preferences

• Do you respond better to a phone call or email?
  
  Phone Call Email
  
  
• Is it okay to text your cell phone?
  
  Yes No
  
  

Text Messaging Consent

TRIO Student Support Services will send me mobile text messaging reminders regarding upcoming appointments, events, and last minute changes to the SSS calendar. I read and I understand the information above. I consent to receiving mobile messages as indicated. I accept that any costs incurred for the messages will by my responsibility and not that of the SSS program.

*Check all that apply to you:

• 	Hispanic/Latino
  	American Indian/Alaskan Native
  	Black/African American
  	White
  	Native Hawaiian/Other Pacific Islander
  	Asian

• *Are you a U.S. Citizen or Permanent Resident?
  
  U.S. Citizen   Permanent Resident   Neither - not eligible; please stop here
  
  
• If you are not a U.S. Citizen, what is your Permanent Resident Alien Number?
  
  

• *Maritial Status:
  
  Single   Married/Partnered   Separated   Divorced  
  
  

High School

• *Are you a high school graduate?
  
  Yes No
  
  
• If no, what is the highest grade completed?
  
  
• *High School Name
• *City and State
• *High School Graduation Date
• *High School GPA (if known)
• *In High School did you participate in:
  
  TRIO Talent Search TRIO Upward Bound N/A
  
  

GED or HiSET

• *Are you a GED/HiSET recipient?
  
  Yes No
  
  
• *GED/HiSET Completion Date:
• *City and State where obtained:

College

• *SCC Program of Study
• What is your current enrollment status?
  
  Full time Part time
  
  
• *Do you have a diploma and/or degree from any college?
  
  Yes No
  
  
• If so, what is your degree?
  
  
• *Do you plan to transfer to a 4-year college?
  
  Yes No
  
  
• *If yes, which college(s) are you considering?
  
  
• How were you referred to TRIO SSS?

• *Did you have an IEP or 504 Plan in high school?
  
  Yes No
  
  
• *Do you have a physical or learning disability?
  
  Yes No
  
  
• *If yes, is your disability documented with SCC Disability Services?
  
  Yes No
  
  

If yes, please provide an accommodations letter from the SCC Disability Services Office. It is policy of SCC and the TRIO SSS program to accommodate students with disabilities. Any student with a documented disability requiring accommodation should contact SCC's Disability Resources Coordinator at 563-441-4027.

The term "first-generation college student" refers to:

• - An individual whose parents did not complete a Baccalaureate (Bachelor's or 4-year college) degree, or
• - In the case of any individual who regulary resides with and received support from only one parent, an individual whose only such parent did not complete a Baccalaureate (Bachelor's or 4-year college) degree.

Highest educational level or grade your parents completed. (Check one for each person)

• *Mother
  
  Did not complete High School
  High School
  College - less than four years
  College - Bachelor's Degree or higher
  
  
• *Father
  
  Did not complete High School
  High School
  College - less than four years
  College - Bachelor's Degree or higher
  
  
  
  
• *As a minor, did you reside with your:
  
  Mother   Father   Both   Other family member(s) or legal guardian(s)
  
  
• *Under the definition above, I am a first-generation college student:
  
  Yes No
  
  

***THIS INFORMATION MUST BE COMPLETE IN ORDER FOR TRIO TO PROCESS YOUR APPLICATION***

Please answer all of the following questions as accurately as possible:

• *Have you applied for Financial Aid?
  
  Yes No
  
  
• *If yes, are you receiving the Pell Grant?
  
  Yes No
  
  
• *I am a(n):

  The federal definition of an independent student is one who meets at least one of the following criteria:

  1. You are working on a degree beyond a bachelor's, such as a master's or doctorate.

  2. You have a child or children, or other legal dependents, who receive more than half their finacial support from you.

  3. You are married (or seperated but not divorced)

  4. You are at least 24 years old.

  5. You are a veteran of the United States Armed Forces.

  6. You are currently serving active duty in the Armed Forces for other than training purposes.

  7. If, at any time since you turned 13, both your parents were deceased, you were in foster care, or were a ward of the court.

  8. You are an emancipated child as determined by a court judge.

  9. You are homeless or at risk of homelessness as determined by the director of a HUD approved homeless shelter, transitional program, or high school liaison.
  

  If you do not meet any of those criterias, you are required to report parental information on your FAFSA, meaning you are classified as a dependent student.

  
  
  Independent Dependent
  
  
• *Please indicate family/household annual Taxable Income for the last year:
• *Number in the household claimed on your (or your parent's) IRS Income Tax Form for the last year (including yourself):
  
  

Federal TRIO Programs Annual Low Income Levels

Size of Family Unit	48 Contiguous States, D.C., and Outlying Jurisdictions	Alaska	Hawaii
1	$18,090	$22,590	$20,790
2	$24,360	$30,435	$28,005
3	$30,630	$38,280	$35,220
4	$36,900	$46,125	$42,435
5	$43,170	$63,970	$49,650
6	$49,440	$61,815	$56,865
7	$55,710	$69,660	$64,080
8	$61,980	$77,505	$71,295

For family units with more than eight members, add the following amount for each additional family member: $6,270 for the 48 Contiguous States, the District of Columbia, and outlying jurisdictions: $7,845 for Alaska, and $7,215 for Hawaii.

The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

The figures shown under family income represent amounts equal to 150% percent of the family income levels established by yhr Census Bureau for determining poverty status. The poverty guidelines were published by the U.S. Department of Health and Human Services in the Federal Register on January 31, 2017.

• *I certify that:
  
  my taxable income for the last year was below the qualifying income levels
  I do not meet the income guidelines
  
  

*Please check all that apply to your current financial aid status:

• 	Applied for Financial Aid
  	Awaiting award notification
  	Received Financial Aid Award Letter
  	Currently working through Financial Aid Verification Process
  	Currently on FA warning, suspension, or probation
  	Have not/will not apply for Financial Aid
  	Have not/will not submit a Federal Tax Return
  	Will supply a copy of tax for, if requested

*Please check all that apply:

• 	Enhance Memory		Improve general study habits
  	Improve grade point average		Improve math skills
  	Improve note-taking skills		Increase reading comprehension
  	Improve spelling		Improve test taking skills
  	Improve time management		Improve vocabulary
  	Improve writing skills		Make career decisions
  	Plan college courses		Receive transfer information
  	Reduce academic anxiety

*Please check any of the following items which describe you:

• 	Afraid of failing in college			Difficulty finding child care
  	Difficulty managing money			Difficulty meeting deadlines
  	Difficulty in finding food sources			Difficulty meeting new people
  	Difficulty participating in discussions			May need personal counseling
  	Minimal computer/internet skills			Easily distracted
  	Test anxiety			Unsure of college expectations
  	Unsure of college procedures			Difficulty with transportation
  	Out of school too long

*What obstacle(s) would most likely prevent you from completing your academic goals?

• 	Financial Concerns			History of alcohol or drug use
  	Homelessness			Inadequate academic preparation
  	No support system			Personal/Health concerns
  	Separation or divorce			Unemployment
  	Legal issues

• *What are your educational goals at SCC and beyond?
• *What have been obstacles, or what do you see as potential barriers to your academic success?
• *Why do you want to be accepted into TRIO Student Support Services?

*Please check all SSS program services you are interested in.

• 	financing college costs			earning good/better grades
  	tutoring services			managing my learning difficulties
  	exploring careers/selecting a career			referrals for assistance with personal concerns such as child care, housing and health care
  	deciding on a major			overcoming test anxiety/ becoming a better test taker
  	using the TRIO Support Center/Computer Lab			transferring to a 4-year school/college visits
  	meeting with the same academic advisor

I authorize the TRIO Student Support Services program staff to:

• - gather information concerning all my academic progress (standardized test scores, transcripts, tutoring, etc.) and financial aid reports including Federal tax, FAFSA and verification of income prior to my particiaption in the program
• - verify my claims of a documented disability with the Disability Services Cooridinator at SCC
• - gather information for follow-up whenever appropriate, including, but not limited to, transfer and progress to 4-year institutions
• - report my eligibility, GPA, and financial aid status to the U.S. Department of Education in accordance with the grant regulations
• - use my name, photo, or information about me in all college media sources

I understand that the completion of this application does not guarantee acceptance to the Scott Community College TRIO Student Support Services program.

I am aware that personal information provided to the TRIO Student Support Services program will be protected under the Federal Education Rights & Privacy Act (FERPA) of 1974.

In case of emergency and aid in the benefit of my well-being, I give constent to the TRIO Student Support Services program staff to:

• - disclose any and/or necessary personally identifiable information from my education records
• - share the identified information above with my emergency contact, parents, college professionals, and/or necessary officials.

Someone who can always receive my mail or be contacted in case of emergency:

• *Name
• *Address
• *Phone Number

The TRIO Student Support Services program will be protected under the Federal Education Rights & Privacy Act (FERPA) of 1974.

The information provided is, to the best of my knowledge, accurate and true.

• *Signature:
• Date: