TRIO Student Support Services 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, email or text?
  
  Phone Call   Email   Text
  
  

*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?
  
  

• *Marital Status:
  
  Single   Married/Partnered   Separated   Divorced  
  
  

• *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
  
  

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

• *SCC Program or Area of Study
• What is your current enrollment status?
  
  Full time (12 credits or more) Part time (11 credits or less)
  
  
• *GPA
• *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 did you hear about 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 Resources?
  
  Yes No
  
  

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 regularly resided 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
  
  Middle School/Junior High
  High School
  College - less than four years
  College - Bachelor's Degree or higher
  
  
• *Father
  
  Middle School/Junior High
  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
  
  
• *Dependency status (explanation below):
  
  Independent Dependent
  
  

  The FAFSA form asks a series of questions that determine whether you are a dependent or independent student for purposes of applying federal aid. (From: https://studentaid.gov/apply-for-aid/fafsa/filling-out)

  Dependency Status Question on the 2022-23 FAFSA Form

  • Were you born before Jan. 1, 1999?
  • As of today, are you married? (Also answer 'Yes' if you are separated but not divorced.)
  • At the beginning of the 2022-23 school year, will you be working on a master's or doctorate program (such as an M.A., MBA, M.D., J.D., Ph.D., Ed.D., graduate certificate, etc.)?
  • Are you currently serving on active duty in the U.S. armed forces for purposes other than training? (If you are a National Guard or Reserves enlistee, are you on active duty for other than state or training purposes?)
  • Are you a veteran of the U.S. armed forces?
  • Do you now have - or will you have - children who will receive more than half of their support from you between July 1, 2022, and June 30, 2023 [during the award year]?
  • Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their support from you, now and through June 30, 2023?
  • At any time since you turned age 13, were both your parents deceased, were you in foster care, or were you a dependent or ward of the court?
  • Has it been determined by a court in your state of legal residence that you are an emancipated minor or that someone other than your parent or stepparent has legal guardianship of you? (You also should answer 'Yes' if you are now an adult but were in legal guardianship or were an emancipated minor immediately before you reached the age of being adult in your state. Answer 'No' if the court papers say 'custody' rather than 'guardianship.')
  • At any time on or after July 1, 2021 were you determined to be an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless, as determined by (a) your high school or district homeless liaison, (b) the director of an emergency shelter or transitional housing program funded by the U.S. Department of Housing and Urban Development, or (c) the director of a runaway or homeless youth basic center or transitional living program?"
  • The above questions were taken from: https://studentaid.gov/apply-for-aid/fafsa/filling-out/dependency

  "What if I answered 'Yes' to one or more of the questions above? If so, then for federal student aid purposes, you're considered to be an independent student and will not provide information about your parents on the FAFSA form." (From: https://studentaid.gov/apply-for-aid/fafsa/filling-out/dependency)

  "What if I answered 'No' to every question? If so, then for federal student aid purposes, you're considered to be a dependent student, and you must provide information about your parents on the FAFSA form." (From: https://studentaid.gov/apply-for-aid/fafsa/filling-out/dependency)

• *Please indicate family/household annual Taxable Income for the last year:
• *Number in the household (including yourself) claimed on your (or your parent's) IRS Income Tax Form for the tax year prior to the last tax year (or in other words, two years back)
  
  

Federal TRIO Programs Annual Low Income Levels

Size of Family Unit	48 Contiguous States, D.C., and Outlying Jurisdictions
1	$19,320
2	$26,130
3	$32,940
4	$39,750
5	$46,560
6	$53,370
7	$60,180
8	$66,990

For family units with more than eight members, add the following amount for each additional family member: $6,810 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $8,520 for Alaska; and $7,830 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 the Census Bureau for determining poverty status. The 2021 poverty guidelines are in effect as of January 13, 2021. Federal Register notice was published February 1, 2021.

*Please check all that apply to your desired needs:

• 	Enhance memory		Improve general study habits
  	Improve grade point average		Improve math skills
  	Improve note-taking skills		Increase reading comprehension
  	Improve test taking skills		Improve time management
  	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 managing money
  	Difficulty in finding food sources		Difficulty meeting deadlines
  	Difficulty meeting new people		Difficulty participating in discussions
  	May need personal counseling		Minimal computer/internet skills
  	Easily distracted		Unsure of college expectations or procedures
  	Out of school too long

• *Why do you want to be accepted into TRIO Student Support Services?

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

• 	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

• Other assistance you would like to receive:

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.

• I ACCEPT consent   I DO NOT accept consent
  
  

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 participation in the program
• - Verify my claims of a documented disability with the Disability Resources Coordinator 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 my consent 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: