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TRiO Student Support Services Program
STUDENT APPLICATION FOR PARTICIPATION
Please print and answer all secons of this applicaon. Your responses are necessary to determine eligibility for this
federally funded program. Because of the personal nature of some of these quesons, your responses will be held in the
strictest condence. The Federal TRiO Programs (TRiO) are federal outreach and student services programs in the United
States designed to idenfy and provide services for individuals from disadvantaged backgrounds. They are administered,
funded, and implemented by the
United States Department of Educaon.
NAME:___________________________________________________ S.S#_________________
LAST FIRST M.I.
ID# _________________
ADDRESS:_________________________________________________________________________
STREET
_________________________________________________________________________
CITY STATE ZIP
PHONE: Home_________________ Cell __________________ GENDER: M_______ F_________
Personal E-mail:_________________________________________ BIRTHDATE:_________________
Student Email:__________________________________________
PROGRAM ELIGIBILITY CRITERIA
Please check one of the following:
U.S. Cizen( ) Permanent Resident( ) Other( )_______________________________________
Please choose any of the following that best represents your ethnicity and/or race:
African American( ) Asian( ) Nave Hawaiian/Pacic Islander( ) Hispanic/ Lano( )
American Indian/Alaskan Nave( ) White/ Caucasian( ) Other (Please Specify)___________________
Tribal Aliaon_____________________________________________________________________________________
Is English your rst language? Yes_____ No______
If no, what is your nave language?_____________________________________
Do Either of your parents have a Bachelor’s degree (a 4-year degree)? Yes_____ No_______
Have you applied for nancial aid? Yes_____ No______
For what term(s)? Summer( ) Fall( ) Spring( ) Year?______________
Have you received your award? Yes____ No____ Pending____
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PLEASE SELECT YOUR INCOME AND HOUSEHOLD SIZE FROM THE GUIDELINE BELOW:
Please check your family size Check household Income Level
____1 ____$17,655 or below per year
____2 ____$23,895 per year
____3 ____$30,135 per year
____4 ____$36,375 per year
____5 ____$42,615 per year
____6 ____$48,855 per year
____7 ____$55,095 per year
____8 ____$61,335 per year
*Federal TRiO Programs 2015 Annual Low Income Levels, eecve 1/28/2015 unl further noce
Do you have a documented disability? Yes____ No_____ If yes, Please specify___________
______________________________________________________________________________
Are you currently serving on acve duty in the U.S. Armed Forces for purposes other than
training? Yes____ No____
Are you a Veteran of the U.S. Armed Forces? Yes____ No____
ACADEMIC ADVISING QUESTIONNAIRE
Did you receive a High School Diploma? Yes____ No____ If yes, what year?____________
If you did not receive a high school diploma, have you earned your GED? Yes____ No_____
Have you taken the College Placement Test? Yes_____ No_____
What services are you interested in receiving at FPCC? (Check all that apply)
_____Peer Mentoring ______Academic Advising ______Cultural Events/Acvies
_____Career Advising ______Student Educaon Plan ______Financial Aid/Scholarship
_____Tutoring ______Personal Counseling ______Financial literacy Seminars
_____Needs Assessment Planning Other (Specify)__________________________________
As an SSS parcipant you will be required to aend a minimum of three of the above listed
services. Mandatory requirements are Financial Literacy and Student Educaon Plan.
*Please answer the following quesons in a few sentences.
Why did you choose to go to college, and why did you select FPCC in parcular?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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What are your career aspiraons? What do you see yourself doing ve years from now?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Is there anything else you would like to share with us that may help us assist you in meeng
your educaonal goals?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
ACKNOWLEGEMENTS
Please read each statement below and inial or check that you understand and agree.
______ I hereby give my permission for the FPCC TRiO– Student Support Services sta to access
my academic and nancial aid records for the purpose of verifying my eligibility and
supporng me academically as a TRiO-SSS parcipant and an FPCC student. I understand
the TRiO-SSS sta agrees to adhere to all guidelines outlined under the Federal
Educaon Rights and Privacy Act.
______ I hereby give my permission for the FPCC TRiO— Student Support Services sta to access
my midterm and semester grades electronically for the purpose of supporng me and
my academic performance at FPCC. I understand that I will have access to my academic
record at any me.
______ YES, I WANT TO BE A MEMBER OF THE FPCC TRiO— STUDENT SUPPORT SERVICES
PROGRAM
*Your applicaon must be lled out completely and signed and dated before it will be processed.
I understand that all of the informaon provided on this form is true and complete.
STUDENT SIGNATURE______________________________________________ DATE________________
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FOR STAFF USE ONLY
Student is enrolled at instuon: Yes_____ No_____
Classicaon: ______Freshman ______Sophmore
______# of credits ______# of credits
Student is eligible for services on the basis of:
_____(1)LI/FG ____(2)LI Only ____(3)FG Only (4)D Only ____(5)LI/D
______LI Vericaon Document on File
______FG reported on SSS and college
applicaons or FAFSA .
______DRS Release of Informaon Request
Cizenship:____ US Cizen____Permanent Resident_____Not cizen or permanent resident
(Permanent Resident # reported on college applicaon___)
Parcipant Type:
___(1)ESL ___(2)Veteran ___(3)Disabled___(4)Foster Child ___(5)Homeless ___(6)N/A
(Ulize applicaon and Interview Form to idenfy parcipant type)
Basis of Academic Need:
______________________________________________________________________________
APR Code:____________
Term Entered Program:_______ Cohort Year:_______ Grant Year:_______
______________________________________________________________________________
Student is ineligible for services on the basis of: Income____ 1st Gen_____ Academic Need____
Other________________________________________
The signing of this form is to cerfy that all documents have been reviewed and eligibility has
been determined
STAFF SIGNATURE______________________________________ DATE___________________
Database Entry Date________________ Entered By____________________________________
Printed name and Inial
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