Fillable Division of Student Services RVC TRIO Student Support (Rock Valley College)

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Division of Student Services RVC TRIO Student Support (Rock Valley College)

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The Student Support Services (SSS) Project of Rock Valley College provides eligible students with FREE academic
advising; financial aid information; financial literacy awareness; career planning; designated computer lab access
(printing services); and tutorial assistance to assist participants in achieving their academic goals. All SSS activities
are designed to assist eligible students persistence in college from year to year; remain in good academic standing
each semester; and graduate from RVC. Students selected to be SSS Participants must meet certain criteria set
forth by the Department of Education.
RVC SSS is a 100% federally-funded TRIO program (253,032 annually for 5 years) under the U.S. Department of Education.
Please complete all questions on the application and return to TRIO SSS Program.
Rock Valley College For assistance with the application:
Division of Student Services RVC TRIO Student Support Services
TRIO Student Support Services 3301 N. Mulford Road, Rockford, IL 61114
RockValleyCollege.edu/TRIO (815) 921-4280
STUDENT SUPPORT SERVICES
CONTACT AND BASIC INFORMATION
Application Date: ______________________________________ ID# ______________________________________ SSN# ______________________________________________________
Date of Birth: __________________________________________ Age: ____________ Gender: ___________________________________________________________________________
Legal Last First Middle
Name: _________________________________________________________________ Name: _________________________________________________________________ Initial: ______________
What do you wish to be called? (if different from legal name): ________________________________________________________________________________________
Check only one:
n U.S. Citizen OR n Permanent Resident OR n Other: _____________________________________________________________
Ethnicity: Are you Hispanic/Latino?
n No, I am not Hispanic/Latino n Yes, I am Hispanic/Latino
Race: What is your race?
n American Indian/Alaska Native n Asian n Black or African American
n White n Pacific Islander n More than one race n Other: _________________________________________________________________
Local Address: ___________________________________________________________________________________________________________________________________________
City: _________________________________________________________________ State: ____________ Zip Code: __________________________________________
Permanent Address: _________________________________________________________________________________________________________________________________
City: _________________________________________________________________ State: ____________ Zip Code: __________________________________________
Rock Valley College | TRIO Student Support Services
3301 N. Mulford Road, Rockford, IL 61114 | (815) 921-4280
TRIO SSS is 100% Founded by the US Department of Education at 253,032
PAGE
1
The financial and non-directory educational record information on your student account is confidential and protected by the Family
Educational Rights & Privacy Act (FERPA). FERPA is also known as the Buckley Amendment, Statute 20 U.S.C. 1232 (g), regulations 34 CRF
Part 99. We cannot release information to another person without your written authorization.
EDUCATIONAL & CAREER INFORMATION
Have you received your: n High School Diploma Date Graduated: ___________________________________________ GPA ___________
n GED Diploma Date Completed: ___________________________________________
Have you previously attended college: n Yes n No If yes, which institution?____________________________________________________________
Did you graduate from this institution? If so, with what degree? ____________________________________________________________________________________
Classification: n freshman (<30 credits) n sophomore (30-65 credits)
What degree plan are you seeking? n A.A.0 n A.S. n A.A.S. n undecided n other, please explain below
Current Enrollment Status:
n Part-Time (<12 credit hours) n Full-Time (>12 credit hours)
Do you plan to transfer after completing your associate’s degree from RVC? n Yes n No
STATEMENT OF AGREEMENT & CONSENT
I certify that the above information contained on this application is true and complete to the best of my knowledge.
I understand that this information will be treated as confidential, but will be reported to the U.S. Department of
Education as a condition of funding for this federally funded program. Further, I understand that the Rock Valley
College TRIO SSS program for students with disabilities will review my transcript and financial aid information to
verify eligibility, determine appropriate services, and track academic progress.
I give the RVC TRIO SSS Program staff permission to obtain any academic or personal information that is
necessary for providing assistance to me, evaluating the effectiveness of the program, and fulfilling federal and
college reporting requirements. This information may be obtained for college departments/personnel, including,
but not limited to: RVC faculty, Services, Dean of Students, Student Life, and peer mentors/tutors.
I give RVC TRIO SSS, its representatives and employees, to take photographs/videos of me and my property in
connection with all TRIO SSS related activities. I authorize TRIO SSS, its assignees and transferees to copyright use
and publish the same in print and/or electronic media. I agree that TRIO SSS may use such photographs of me with
or without my name for lawful purposes, including, but not limited to, publicity, advertising, social media and web
content in connection with TRIO SSS.
By signing, I attest that all the information on this application is true.
_____________________________________________________________________ __ _________________________________________
Student’s Signature Date
STUDENT SUPPORT SERVICES
Rock Valley College | TRIO Student Support Services
3301 N. Mulford Road, Rockford, IL 61114 | (815) 921-4280
TRIO SSS is 100% Founded by the US Department of Education at 253,032
PAGE
2
STUDENT SUPPORT SERVICES
Rock Valley College | TRIO Student Support Services
3301 N. Mulford Road, Rockford, IL 61114 | (815) 921-4280
TRIO SSS is 100% Founded by the US Department of Education at 253,032
PAGE
3
Check all areas in which you feel TRIO SSS staff may be able to assist you:
n Academic Coaching — Receive assistance in choosing classes to stay on track to graduate on time.
n Career Counseling — Receive support in determining the best college major and career for you.
n Tutoring — Receive personal one-on-one tutoring in select subject areas at no cost to you.
n Financial and Economic Literacy — Learn about managing a budget and making wise financial decisions.
n Learning Styles and Study / Test Taking Skills — Assistance in identifying your style of learning and some
strategies to study and take tests successfully.
n Graduation and Enrollment in University — Receive assistance in graduation from RVC and
4-year school enrollment.
n Financial Aid Information and Assistance Applying — Assistance completing FAFSA annually.
Learn about scholarships and other financial aid options.
FINANCIAL AID AND DEPENDENCY STATUS
Have you completed a FAFSA? n Yes n No
Are you receiving financial aid this semester? n Yes n No
If yes, what is your dependency status? n Independent Student n Dependent Student n Don’t Know
By signing this application, I attest that all the information is true. Moreover, I authorize the release of the my
academic and financial records to TRIO-SSS, understanding that the information on these records will be used
only to assess my need for Project services, monitor my educational process, and fulfill program reporting
requirements.
__________________________________________________________________________________
Student’s Name – please print
__________________________________________________________________________________ ___________________________________________
Student’s Signature Date
ACADEMIC & SUPPORTIVE SERVICES NEEDS ASSESSMENT
STUDENT SUPPORT SERVICES
Rock Valley College | TRIO Student Support Services
3301 N. Mulford Road, Rockford, IL 61114 | (815) 921-4280
TRIO SSS is 100% Founded by the US Department of Education at 253,032
PAGE
4
ONLY complete ONE of the following Educational Attainment & Income Forms
(Dependent OR Independent)
NOT BOTH FORMS
NOTE: Taxable Income can be found on the federal income tax return,
IRS Form 1040, line 10
Please bring a copy of your parent’s 2019 tax return, a transcript of the return,
or a Verification of Non-filing letter from the IRS.
DEPENDENT STUDENTS ONLY
2020-2021
To be Completed and Signed by the Student’s Parent/Legal Guardian
Student’s Name: _____________________________________________________________________________________________________________________________________________________________________
Name of Parent/Legal Guardian: ________________________________________________________________________________________________________________________________________
Parent’s Parent’s
Phone No.: ____________________________________________________ Email Address: __________________________________________________________________________________________
Did Mother of Student earn a 4-year degree from a college/university?
n Yes n No
Did Father of Student earn a 4-year degree from a college/university?
n Yes n No
Number of people living in parent/legal guardian’s household?
What was parent/legal guardian’s 2019 TAXABLE* INCOME? $ ______________________________
*This is NOT adjusted gross income and is listed on the 2nd page of most tax forms.
All of the information on this form is true and complete to the best of my knowledge.
__________________________________________________________________________________
Parent/Legal Guardian – please print
__________________________________________________________________________________ ___________________________________________
Parent/Legal Guardian Signature Date
DEPENDENT STUDENTS ONLY
ONLY complete ONE of the following Educational Attainment & Income Forms
(Dependent OR Independent)
NOT BOTH FORMS
STUDENT SUPPORT SERVICES
Rock Valley College | TRIO Student Support Services
3301 N. Mulford Road, Rockford, IL 61114 | (815) 921-4280
TRIO SSS is 100% Founded by the US Department of Education at 253,032
PAGE
5
ONLY complete ONE of the following Educational Attainment & Income Forms
(Dependent OR Independent)
NOT BOTH FORMS
NOTE: Taxable Income can be found on the federal income tax return,
IRS Form 1040, line 10
Please bring a copy of your 2019 tax return, a transcript of the return,
or a Verification of Non-filing letter from the IRS.
INDEPENDENT STUDENTS ONLY
2020-2021
To be Completed and Signed by the Student
Student’s Name: _____________________________________________________________________________________________________________________________________________________________________
RVC student ID#: ____________________________________________
Phone No.: ______________________________________________________ Email Address: __________________________________________________________________________________________
Did Mother of Student earn a 4-year degree from a college/university?
n Yes n No
Did Father of Student earn a 4-year degree from a college/university?
n Yes n No
Number of people living in student’s household?
What was student’s 2019 TAXABLE* INCOME? $ ______________________________
*This is NOT adjusted gross income and is listed on the 2nd page of most tax forms.
All of the information on this form is true and complete to the best of my knowledge.
__________________________________________________________________________________
Student’s Name – please print
__________________________________________________________________________________ ___________________________________________
Student’s Signature Date
INDEPENDENT STUDENTS ONLY
ONLY complete ONE of the following Educational Attainment & Income Forms
(Dependent OR Independent)
NOT BOTH FORMS
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Division of Student Services RVC TRIO Student Support (Rock Valley College)

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Completed 25 July 2020

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