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