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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