2020-21 STUDENT APPLICATION
Student Support Services (SSS/TRIO)
PERSONAL DATA *all information will be held in strict confidence in compliance with the Family Educational Rights and Privacy Act
Today’s Date: _________________ Birth Date: Month ______ Day _____ Year _____ (required)
Century Student ID # :______________________________ (required)
Name _________________________________________________________________________________
Last First Middle
Address ______________________________________________________________________________
Number/Street Apt. No.
______________________________________________________________________________
City State Zip
Phone Home (_____)___________________ Work (_____) ___________________________
Cell (_____)____________________ E-Mail address: ___________________________
Gender: Marital Status: Citizenship Status:
___1. Male ___ Single ___ U.S. Citizen
___2. Female ___ Married ___ Resident Alien
___ Permanent Resident of Trust Territories
___ Other (______________________)
Are you Hispanic or Latino
(a person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture, regardless of race)
?
Yes _____ No _____
Racial background (select one or more)
_____ American Indian or Alaska Native - A person having origins in any of the original peoples of North and
South America (including Central America) who maintains cultural identification through tribal affiliation or
community
attachment.
_____ Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian
subcontinent.
_____ Black or African American - A person having origins in any of the black racial groups of Africa.
_____ Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
_____ White - A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
REFERRAL: How did you hear about Student Support Services ? _______________________________
For SSS Use Only: Eligibility Code__________ Need Code___________ First Enroll Date__________ Project Entry Date___________
Staff___________
INCOME ELIGIBILITY (completion of this section is required )
1) Are you receiving financial aid? YES or NO(CIRCLE ONE) If yes, print a copy of your award letter.
2) For financial aid purposes, are you considered DEPENDENT** or INDEPENDENT? (CIRCLE ONE)
** Generally, if you are under 24 years of age, single, and have no children, you are a DEPENDENT.
If DEPENDENT, parent must complete this section If INDEPENDENT, student completes this section
Select the range that your 2019 taxable income falls in:
$0 to $19,140
$19,140 to $25,860
$25,860 to $32,580
$32,580 to $39,300
$39,300 to $46,020
$46,020 to $52,740
$52,740 to $59,460
$59,460 to $66,180
How many family members are in your
household?
__________
Parent Name: ______________________________________
(please print)
Parent Signature: ___________________________________
Select the range that your 2019 taxable income falls in:
$0 to $19,140
$19,140 to $25,860
$25,860 to $32,580
$32,580 to $39,300
$39,300 to $46,020
$46,020 to $52,740
$52,740 to $59,460
$59,460 to $66,180
How many family members are in your household,
including yourself? ___________
Applicant Signature: ___________________________________
HOUSEHOLD INFORMATION (any applicant who is a parent with children must complete)
NAME OF CHILD DATE OF BIRTH (MM/DY/YR)
_______________________________________________ __________________________
_______________________________________________ __________________________
_______________________________________________ __________________________
_______________________________________________ __________________________
PARENT EDUCATION
What is the highest level of education completed by your parents? Check one for each parent.
Grade
School
(grade 1-6)
High
School
(grade 7-12)
Some
College
(No
Degree)
2-Year
College
Degree
(Associate’s
Degree)
4-Year
College
Degree
(Bachelor’s
Degree)
Graduate
Degree
Unknown
Mother
Father
If you were raised in a single-parent household prior to age 18 and that single-parent did not
receive a 4-year degree, check here.
STUDENT DISABILITY INFORMATION
1. Are you registered with or receiving disability services through Century’s Access Center?
_____ Yes _____ No
2. If yes, please identify your disability: ______________________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
STUDENT EDUCATIONAL HISTORY
Do you plan to receive a degree? yes no If yes, what degree?________________________________
Do you plan to transfer?
yes no
Please list all other colleges and universities you have attended. Include dates and degree/diploma attained, if
applicable
:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
APPLICANT’S PERSONAL STATEMENT (please address the following points)
1. Briefly explain your educational and career goals.
2. Do you plan to be a full-time or part-time student?
3. What help might you need to complete your goals?
How can we help you complete your goals? (check all that apply)
Academic Skills:
Time Management
Study Skills
Test Taking/Test Anxiety
Reading Comprehension
Writing
Organization
Note Taking
Math Skills
Basic Computer Skills
Tutoring
Learning Strategies
STUDENT CERTIFICATION and RELEASE
I, the above named applicant, certify that the information I have provided on this application is complete and correct. I
authorize SSS staff to obtain records or data in support of my application from other sources, and to release information
as required by the grant-funding agency of the United States Government. I agree that if I am accepted into SSS,
program staff may have access to my academic and financial aid records and may include my name as a participant in
SSS publications. Note: SSS is a federally funded TRIO program. The US Dept. of Education requires reporting
by Social Security number. If accepted into the program, you will be required to provide this information.
_____________________________________ _____________________
Student Signature Date
Your SSS application must be completed, signed and returned to the address below before you can be evaluated
for admission into the Student Support Services (SSS/TRIO) Program. Submit your application to:
Student Support Services (SSS/TRIO)
Room 2460 (West)
3300 Century Avenue, White Bear Lake, MN 55110
Questions? Please call us at 651.779.3226
Minnesota state Colleges and Universities is committed to a policy of nondiscrimination in employment and education opportunity. No person shall be
discriminated against in the terms and conditions of employment, personnel practices, or access to and participation in, programs, services, and
activities with regard to race, sex, color, creed, religion, age, national origin, disability, marital status, status with regard to public assistance, sexual
orientation, or membership or activity in a local commission as defined by law.
This publication can be made available in an alternative format
to individuals with disabilities by calling
651-779-3354, TTY 651-773-1715, or
through the Minnesota Relay Service at 1-800-627-3529
Advising and Career:
Career Planning
Choosing a Major
Academic Advising/Planning/Course Selection
Transfer Planning
Goals/Decision Making
Financial Aid Advising
Other:
Financial Literacy
_________________________________
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