2019-2020 Participant Application
Student Success Center Community College of Aurora
The Community College of Aurora TRIO Student Support Services-English as a Second Language
(SSS-ESL) program is a federally funded TRIO Program under the U.S. Department of Education.
It is designed to assist students to graduate from college. Program participants must meet certain
eligibility criteria set forth by the Department of Education. To determine you eligibility, please fill
out the following information COMPLETELY. Incomplete applications will not be processed.
The information you provide is confidential and protected through the
FERPA Rights and Privacy Act (FERPA)
CCA S#: _______________________________
Date of Birth: ______/______ /_______ Gender: Male Female Prefer Not to Answer
First Name: __________________________________ Last Name: ______________ MI: ______
Address: ______________________________________________________________________
Cell phone: _________________________________ Alt. Phone: _________________________
Preferred Email: ________________________________________________________________
Is English your First language? Yes No If NO, what is your first language? ______________
What Country are you from? ______________________________________________________
American Indian/Alaska Native Asian Pacific Islander Black/African American
Latino/a Native Hawaiian White Other ________________
Are you a U.S. Citizen? Yes No Are you a Permanent Resident? Yes No
If YES to Permanent Resident, please enter your Permanent Resident Card #? _______________
Please continue to next page/back side!
Please tell us what TRIO services you plan to use (Check all that apply):
One on One Advising with Assigned Advisor
Career Planning
Tutoring in English, Math, and/or Science
Transfer Planning
General Study Skills
Academic Planning
Financial Aid/Scholarship Information
Time Management Skills
College Visits
Academic Development Workshops
Background Information:
Have either of your biological or adoptive parents earned a bachelor’s degree or higher?
Yes-Mother Yes-Father Neither Unsure/Unknown
Have you earned a bachelor’s degree or higher? Yes No
Do you have any documented disability? Yes No
If YES, is this information on file with CCAs Office of Disability and Equity? Yes No
If you would like to disclose your disability, please do so here (This voluntary information will be kept
confidential. Refusal to provide it will not subject the applicant to any discrimination on the basis of
handicap): __________________________________________________________________
What credential are you currently working towards at CCA?
Certificate Associate of Arts Associate of Science Associate of General Studies
Associate of Applied Science Articulated Degree None/Fulfilling Prerequisites
Do you plan to transfer to a 4-year university to obtain a Bachelor’s degree?
Yes No
Program Benefits include:
A dedicated academic coach
Tutoring in English, Math and/or Science
Assistance with academic and degree
Access to cultural events and activities
Assistance with the transfer process
(transfer exploration, application
completion, financial aid and scholarships)
TRUTH STATEMENT: The information provided on this form is, to the best of my
knowledge, accurate and true.
_____________________________________________ ______________________
Student Signature Date
Please return your completed application to:
Student Success Center -TRIO Student Support Services-English as Second Language
16000 E. Centretech Parkway, Student Center S101 or S203
Phone: 303-360-4754 Email:
The below documents may be required of you during an interview if you are eligible for the program:
A copy of the previous year tax returns
Permanent resident card or proof of citizenship status (If the applicant is a non-citizen)
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