TRIO-Student Support Services Program Application

Federally Funded Program

TRIO-Student Support Services Program Application

The TRIO-Student Support Services program provides opportunities for academic development, assists students with basic college requirements, and serves to motivate students towards the successful completion of their postsecondary education. The goal of TRIO SSS is to increase the college retention and graduation rates of its participants and facilitate the process of transition from one level of higher education to the next. The program provides an interconnected series of academic support services: study skills development to achieve academic success, tutoring to master course content, and intensive academic, financial, or personal counseling.

Name: ______Social Security Number: ______DOB___/__/_____

Address: ______

City: ______State: ______Zip: ______

Phone number Home: (____)______Work: (____)______Cell: (__)______

Please clearly print your email address: ______

Ethnicity:
Hispanic or Latino? Yes ____No ____
Race: (please answer)
American Indian/Alaskan Native? Yes ___No___
Asian Yes ____No____
Black/African-American Yes ___No____
White Yes ____No____
Nat. Hawaiian/Pacific Islander Yes ____No ____ / Citizenship: (check one)
___ U.S. Citizen
___ Permanent Resident (Resident Alien #. :
A______)
Gender:
___ Male ___ Female

Please answer the following questions by circling YES or NO:

Do either of your parents have a degree from a four year college? YES NO

Father’s highest level of education ______

Mother’s highest level of education ______

Are you receiving financial aid? YES NO

If yes, what type: ______

Do you have any special needs or concerns? YES NO

If yes, please explain: ______

Do you have a documented disability? ______YES ______NO

Do you plan to earn an Associate’s degree from WCC? YES NO

If yes, what is your target graduation date: ______

Semester Year

Do you intend to complete your degree as a full-time student? YES NO

(12+ per semester)

Do you plan to transfer to a four-year college? YES NO

If yes, when do you plan to transfer: ______

Semester Year

Name of college planning to transfer to: ______

Have you previously participated in TRIO Student Support Services, Upward Bound,

Educational Opportunity Center, Talent Search or McNair Program? YES NO

What is your reason for enrolling in the Student Support Services Program?

______

______

______

I certify all information provided, including financial and family documentation, in conjunction with this application is complete and accurate to the best of my knowledge. Furthermore, I authorize the SSS staff to obtain records or data pertinent to my participation from other sources, and to release information to the U.S. Department of Education TRIO Program. The SSS Staff also has my permission to communicate with WCC staff and faculty and/or other professionals on my behalf. I give permission to release my name/photo to provide recognition in the TRIO-Student Support Services Newsletter and other publications.

______

Student signature Date

Notice of nondiscrimination

Admission to TRIO-SSS program is based on availability of space and eligibility of the applicant without regard to race, color, creed, gender, age, marital status, national origin, sexual orientation or handicap.

Funded 60% by the US Department of Education.

Total dollar amount of Federal Funding : $255,012

Number of students served per year: 170