Fillable Form 1: TRiO Student Support Services Program STUDENT (Fort Peck Community College)

Fill Online, Printable, Fillable, Blank Form 1: TRiO Student Support Services Program STUDENT (Fort Peck Community College) Form

Use Fill to complete blank online FORT PECK COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: TRiO Student Support Services Program STUDENT (Fort Peck Community College)

On average this form takes 23 minutes to complete

The Form 1: TRiO Student Support Services Program STUDENT (Fort Peck Community College) form is 4 pages long and contains:

  • 0 signatures
  • 88 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Fort Peck Community College

BROWSE FORT PECK COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
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____
2
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?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3
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________________
4
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1: TRiO Student Support Services Program STUDENT (Fort Peck Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document