1
Rev.5/2020
20192020
TRIOSTUDENTSUPPORTSER VICESAP PLICATIO N
PertheFamilyEducationalRightsandPrivacyAct(FERPA),informationinthisapplicationisconfidential‐wewill
protectyoursensitivepersonaldata.PRINTCLEARLY.AllsectionsoftheapplicationMUSTbecompleted.
Incompleteapplicationsmaybereturnedtoyouorrejected.
Name
OCID (To be filled out by Owens staff)
Street City/State Zip
Phone DOB
SSN (To be filled out by Owens staff)
Owens Student Email
Inaccordancewithfederalregulations,astudentmustmeetoneofthefollowingcriteriatobe
eligibleforprogram
services:
Afirstgenerationcollegestudent(neitherparentorguardianhasaBachelor’sdegree)
Limitedincome(verifiedbyanSSSstaffmember)
Haveadocumenteddisability*
Ifyes,haveyouregisteredwiththeOCCDisabili
tyResourceCenter?Yes No
DEMOGRAPHICDATA
Widowed
(Note:theU.S.DepartmentofEducationwillnotrecognizeotherdesignationsoutsideofthoselistedbelow.)
Gender: Male Female MaritalStatus: Single Married Divorced
CitizenshipStatus: U.S.citizen PermanentResident Other:___________________
RaceorEthnicity(checkallthatapply):
BlackorAfricanAmerican HispanicorLatino White
NativeHawaiianorotherPacificIslanderAmericanIndianorAlaskaNative Asian
DoyouspeakEnglishasaSecondLanguage(ESOL)? Yes No
Ifyes,primarylanguagespoken:____________________________________
WereyoueveramemberofanyofthefollowingAccessPrograms? NO
YES: check which one(s) below:
UpwardBound EducationalTalentSearch EOC
Other______________________________
ACADEMICINF O RMATION 
Major:________________________________AcademicAdvisorName:______________________________________
HighSchoolGPA(iflessthan3yearsaftergraduation):_________
WhatisyourexpectedyearofgraduationfromOwens?________ Full PartTime
WhatisyourcurrentOwensStateCommunityCollegeacademicstatus?
Newstudent,regularadmission
Newstudent,FalconExpress,
RocketExpress
Transferstudent
Goodstanding
Warning
Probation
MayContinue(previouslydismissed
orsuspendedfromOwens)
2
Rev.5/2020
FINANCIALELIGIBILITY
Ifyouand/oryourfamilyfiledincometaxeslastyear,whatwasyourcombinedTAXABLEINCOME?Note:ItisREQU
IRED
thatyouindicateTAXABLEincomeandnottotalincomeoradjustedgrossincome.Taxableincomeisreportedon:line
10ofform1040.(PleasenoteyourapplicationwillbeincompletewithouttheREQUIREDFIELDSmarkedwitha*)
Lessthan$58,515
Lessthan$65,145
Lessthan$18,735
Lessthan$25,365
Lessthan$31,995
Lessthan$38,625
Lessthan$45,255
Lessthan$51,885
* Numberofpeoplelivinginyourhouseholdincludingyourself_______
* Areyou
designatedasanIndependentStudentforfinancialaidhereatOwens? Yes No
* Pleasecheckallthatapply:(ifnotapplicablepleaseskip)
AParentAtleast24yearsold
Orphan/WardofCourt Homeless
AVeteran
Agedoutoffostercare
Haveyoucompletedanundergraduatedegree?(Note:Ifso,youarenoteligibletojoinSSS)
Hasitbeendeterminedbyacourtinyourstateoflegalresidencethatyouareanemancipatedminororthat
youareinalegalguardianship?
IherebycertifytheinformationIhavefurnishedregardingthesizeofmyfamilyandtaxableincomeistrueto
thebestofmyknowledgeandherebygrantOwensStateCommunityCollegeTRIOStudentSupportServices
permissiontohaveaccesstomyofficialrecordsinordertocompletemyapplication.(Yourapplicationwillnot
becompletewithoutsignaturesanddates.)
IgiveStudentSupportServices(SSS)mypermissiontoaccessmyeducationalrecordsandothermaterials
necessaryforparticipationintheSSSProgram.Furthermore,Iunderstandthatallmyrecordsarekept
confidentialandinaccordancewithOwensCommunityCollegeandFederalPrivacyLaws.
Icertifythattheaboveinformationiscompleteandaccuratetothebestofmyknowledge.
Igivepermissionforreleaseofmydata(name,photos,datarelatedtoawardsandachievements)forpurposeof
awards,recognitionandadvertising.
Permissiontotakemypictureforrecognitionandadvertisingpurposes: Yes
No
Pleasesign,dateandreturnthisform.Ifyouareconsideredadependent,asdefinedbyFreeApplicationforFederal
StudentAid(FAFSA),youmusthaveyourparent/guardiansignanddatethisform.
By typing your name in the signature box you are acknowledging that all the information being supplied is accurate
and can be verified with official documentation. Typing in the signature box will serve as your official signature until a
signature can be obtained in person.
Printstudentname:_________________________________StudentSignature:_______________________________
Date:__________________
Printparent/guardianname(ifclaimedasdependent):____________________________________________________
ParentorGuardianSignature:____________________________________________________Date:________________
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Rev.5/2020
NEEDSASSESSMENTSURVEY
Asastudent,Iwantto:(Checkallthatapply)
Improvegeneralstudyhabits Improvemathskills Improvespelling
Improvenotetakingskills Improvevocabulary Reducemath/testanxiety
Improvetimemanagementskills Improvetesttakingskills Developaplanforcollegecourses
Increasecollegereadingspeed Enhancememory Makegoodcareerdecisions
Improvecol
legereadingcomprehension Improvegradepointaverage Receivetransferassistance
Pleasecheckanyofthefollowingitemswhichdescribeyou:
Outofschooltoolong Difficultymeetingdeadlines Panicduringtests
Afraidoffailingincollege Unsureofcollegeprocedures Fewcomputerskills
Difficultyfindingchildcare Difficultyparticipatingindiscussions
LimitedexperienceusingInternet
AfraidImightnotfitinatOwens Difficultywithpublicspeaking Difficultymanagingmoney
Difficultymeetingnewpeople Difficultywithorganizing/prioritizing Mayneedpersonalcounseling
Notpreparedforcourselevel Unabletou
nderstandcoursecontent Conflictwithprofessor
Registeredfortoomanyclasses Changedmajoroneormoretimes Workingtoomuchduringweek
Whatobstacle(s)wouldmostlikelypreventyoufromcompletingyouracademicgoals?(Checkallthatapply)
Poorstudyhabits Badgrades Familymedicalproblems
Lackofmoney Takethingstooseriously Separationordivorce
Takingthewrongclasses Problemsathome NoclosefriendsatOwens
Alwaysfeelingtired Troublesleeping Easilydistracted
Recurringhealthconc
erns Afraidtospeakupinclass Tooshy
Alcoholand/ordrugproblems Feelingdepressedorsad Alwaysworrying
Nosupportfromfamily/friends Dealingwithbills Testanxiety
MymostimportantareaswhichIwillneedassistanceare:(Checkallthatapply)
Financial: PersonalIssues: Transfertoa4yearInstitution: Career:
PersonalBudget StressManagement SearchProcess Interviewing
FAFSA SubstanceAbuse ApplicationProcess Resume/CoverLetter
Grants/Scholarships Relationships Funding JobSearching
Loans Anxiety Planning Coop/Internship
Depression Transcri
pts LeadershipDevelopment
Academic: Motivation Goals/DecisionMaking
CourseSelection ExploringDiversity
SelectingaMajor TimeManagement
Practicum Organization/Prioritization
Myskillsineachoftheareasbeloware:(Checktheappropriatebox)
Excellent AboveAverage Average Fair Poor
Math
Scien
ce
Reading
    
Writing
StudyStrategies
Describeapersonalstrengthwhichyoufeelwillhelpyoubesuccessfulasastudent:
AftergraduationfromOwensCommunityCollege,Iplanto:
4
Rev.5/2020
Note:Applyingforthisprogramisacommitmentandweexpectyoutobeanactiveparticipantwhileyou
areastudentatOwensCommunityCollege.
Ifyouareadm
ittedtoOwensCommunityCollegeTRIOStudentSupportServices,wewillrequirethefollowing
commitmentfromyou:
IWILLmeetwithmySSSadvisoratleasttwiceasemester.
IWILLparticipateintu toringsessionsasneeded.
IWILLparticipateinSSSfinancialaidandcare
erdevelopmentworkshopsandevents.
IWILLsetgoalswithmySSSadvisorthatleadtomyplannedgraduation/transferfromOwensCommunityCollege.
CompletedapplicationsMUSTbeemailedfromanOwensCommunity
CollegeStudentemailaccount.
Nopaperapplicationswillbeacceptedatthistime.
Instructions for submission:
1. Complete all sections of the application. Application is a fillable pdf that can be
compl
e
ted on your computer or tablet.
2.
Save the completed pdf file to your desktop or local drive
on your computer or tablet.
3.
Email the completed application as an attachment from your Owens St
udent Email
account to stud
entsupportservices@owens.edu
with the subject line “SSS
Application—“Student Name”
4. A TRIO Student Support Services staff member will contact the
applicant within 72
business hours to schedule a virtual int
ake intervie
w.
Return to: TRIO Student Support Services
Email:studentsupportservices@owens.edu
(Pleaseindicate“SSSApplication—STUDENTNAME”inthesubjectline)
Phone:(567)6617300
HowdidyoulearnaboutOwensTRIOStudentSupportServices?
OwensStaff/Faculty:____________________Mailing/Flyer TRIOStudent:_________________________
EMail OwensWebsite Other:_______________________________
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