TRIO Student Support Services Application Page 1 of 2 Revised May 2020
TRIO Student Support Services
APPLICATION FORM
For fillable application, download PDF, complete,
then print to PDF to save and email!
TRIO Student Support Services (SSS) is a federal grant program that support students toward achieving academic success.
Demographics:
Legal Name _________________________________________________________________________SSN# _____________________
Last First Preferred MI
Local Mailing Address__________________________________________________________________________________________
Street/P.O. Box City State Zip
Permanent Mailing Address ______________________________________________________________________________________
Street/P.O. Box City State Zip
Phones _____________________________________________________________________ Check if okay to text message _____
Cell Home Work/Other
Email (that you check daily): ________________________________________________________________________________________
Date of Birth ________________ CWC Student ID# _______________________
Preferred Gender Female Male Marital status Married Divorced Separated Single Widow/Widower
Ethnicity What is your ethnicity? Are you Hispanic or Latino? Yes No
Race (check all that apply) Black/African American Native Hawaiian/Other Pacific Islander Asian American
White American Indian/Alaska Native Hispanic/Latino
Eligibility:
1. Citizenship/Residency Status
Are you a U.S. citizen? Yes No If NO, from your Permanent Resident Card, please provide your USCIS #_________
2. Degree Status
Have you already earned an Associate’s or Bachelor’s degree? No Yes
If YES, stop here, not qualified!
3. First Generation College Student
a. Did your mother/caregiver receive a bachelor’s (4-yr) degree before you were 18-yrs old? Yes No Unknown
b. Did your father/caregiver receive a bachelor’s (4-yr) degree before you were 18-yrs old? Yes No Unknown
c. Whom did you primarily live with before your 18
th
birthday? Mother Father Both Other _____________
4. Income Eligibility
I was claimed on my parents’ income tax return
I am 24 years of age or older.
I am married.
I have dependents other than a spouse.
a. Are you receiving a Pell Grant? □ Yes □ No
b. Taxable income and/or your parent’s taxable income if dependent on last year’s income tax return________________
c. What is the number of exemptions claimed on the tax return? _________
*Parent/Guardian Signature (if dependent) or Your Signature (if independent)_______________________________________
5. Are you a USA veteran (with other than dishonorable discharge)? Yes No
6. Will you be requesting educational and/or physical accommodations related to a disability? Yes No
(CWC encourages individuals with disabilities to inform the college of their needs and provide documentation at least a month prior to the beginning of the
semester they plan on attending to coordinate services.)
Academic Need: (Please check all that apply)
Academic Proficiency Tests
Failing Grades
High School Equivalency (GED / HSEQ)
Lack of Academic Preparedness For College Level
(Struggle in Math, English or Reading)
Lack of Educational and/or career goals
Limited English Proficiency
Low Admission Test Scores (ACT, COMPASS, ALEKS)
Low College Grades
Low High School Grades
Need for Academic / Personal Support to raise grades
Other _________________________________
Out of the Academic Pipeline for 5 or More Years
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TRIO Student Support Services Application Page 2 of 2 Revised May 2020
Student Information:
Is this your first year of college? (not including dual credit courses) Yes No
What degree would you like to obtain: License/Credential Associate’s Degree Bachelor’s Degree Master’s Degree +
What is your intended major? ___________________________Do you plan to transfer to a 4-year college/university Yes No
Where? _______________________________________ Anticipated semester & year of transfer: _____________________
Verification and Release of Information:
I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that this
information is confidential and will be used for grant purposes. I hereby authorize TRIO Student Support Services (SSS) to secure
information pertinent to my participation in TRIO SSS at Central Wyoming College. This release covers, but is not limited to, access to
financial aid information, standardized test scores, transcripts, grade reports, and any information concerning my academic progress
and performance. The TRIO SSS office will request and share this information as deemed necessary or upon student request to
further student success, while remaining compliant with CWC FERPA policies.
NOTICE: We sometimes name and photograph participants at Program events. Please inform us if you do not want your name and/or
photograph used in our materials or website, by circling NO DIRECTORY below.
___________________________________________ _______________________
Student Signature Date NO DIRECTORY
Thank you for completing the TRIO Student Support Services Application. Please deliver or email to a staff member
below
. We look forward to seeing you at Central Wyoming College. Student Support Services staff will contact you soon after
verifying your enrollment in classes at Central Wyoming College to schedule a program orientation.
Central Wyoming College TRIO Student Support Services
Main Hall Room 121, 123, 133
2660 Peck Avenue
Riverton, WY 82501
studentsupportservices@cwc.edu
Deryle Matland
Program Manager
307-855-2227
dmatland@cwc.edu
Whitney Martinez
Education/Skills Development
Coach and Tutoring Services
307-855-2117
wmartine@cwc.edu
Paula Hartbank
Education/Transfer Coach
307-855-2169
paula@cwc.edu
Matt Myers
Education/Retention Coach
and Mentoring Program
307-855-2228
msmyers@cwc.edu