Fillable Form 20192020: TRIOSTUDENTSUPPORTSER VICESAP PLICATIO N (Owens Community College)

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Form 20192020: TRIOSTUDENTSUPPORTSER VICESAP PLICATIO N (Owens Community College)

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1

Rev.5/2020

2019‐2020

TRIOSTUDENTSUPPORTSER VICESAP PLICATIO N

PertheFamilyEducationalRightsandPrivacyAct(FERPA),informationinthisapplicationisconfidential‐wewill

protectyoursensitivepersonaldata.PRINTCLEARLY.AllsectionsoftheapplicationMUSTbecompleted.

Incompleteapplicationsmaybereturnedtoyouorrejected.

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

Inaccordancewithfederalregulations,astudentmustmeetoneofthefollowingcriteriatobe

eligibleforprogram

services:

Afirstgenerationcollegestudent(neitherparentorguardianhasaBachelor’sdegree)

Limitedincome(verifiedbyanSSSstaffmember)

Haveadocumenteddisability*

Ifyes,haveyouregisteredwiththeOCCDisabili

tyResourceCenter?Yes No

DEMOGRAPHICDATA

Widowed

(Note:theU.S.DepartmentofEducationwillnotrecognizeotherdesignationsoutsideofthoselistedbelow.)

Gender: Male Female MaritalStatus: Single Married Divorced

CitizenshipStatus: U.S.citizen PermanentResident Other:___________________

RaceorEthnicity(checkallthatapply):

BlackorAfricanAmerican HispanicorLatino White

NativeHawaiianorotherPacificIslanderAmericanIndianorAlaskaNative Asian

DoyouspeakEnglishasaSecondLanguage(ESOL)?  Yes No

Ifyes,primarylanguagespoken:____________________________________

WereyoueveramemberofanyofthefollowingAccessPrograms? NO

YES: check which one(s) below:

UpwardBound EducationalTalentSearch EOC

Other______________________________

ACADEMICINF O RMATION 

Major:________________________________AcademicAdvisorName:______________________________________

HighSchoolGPA(iflessthan3yearsaftergraduation):_________

WhatisyourexpectedyearofgraduationfromOwens?________ Full Part‐Time

WhatisyourcurrentOwensStateCommunityCollegeacademicstatus?

Newstudent,regularadmission

Newstudent,FalconExpress,

RocketExpress

Transferstudent

Goodstanding

Warning

Probation

MayContinue(previouslydismissed

orsuspendedfromOwens)

2

Rev.5/2020

FINANCIALELIGIBILITY

Ifyouand/oryourfamilyfiledincometaxeslastyear,whatwasyourcombinedTAXABLEINCOME?Note:ItisREQU

IRED

thatyouindicateTAXABLEincomeandnottotalincomeoradjustedgrossincome.Taxableincomeisreportedon:line

10ofform1040.(PleasenoteyourapplicationwillbeincompletewithouttheREQUIREDFIELDSmarkedwitha*)

Lessthan$58,515

Lessthan$65,145

Lessthan$18,735

Lessthan$25,365

Lessthan$31,995

Lessthan$38,625

Lessthan$45,255

Lessthan$51,885

* Numberofpeoplelivinginyourhouseholdincludingyourself_______

* Areyou

designatedasanIndependentStudentforfinancialaidhereatOwens? Yes No

* Pleasecheckallthatapply:(ifnotapplicablepleaseskip)

AParentAtleast24yearsold

Orphan/WardofCourt Homeless

AVeteran

Agedoutoffostercare

Haveyoucompletedanundergraduatedegree?(Note:Ifso,youarenoteligibletojoinSSS)

Hasitbeendeterminedbyacourtinyourstateoflegalresidencethatyouareanemancipatedminororthat

youareinalegalguardianship?

 IherebycertifytheinformationIhavefurnishedregardingthesizeofmyfamilyandtaxableincomeistrueto

thebestofmyknowledgeandherebygrantOwensStateCommunityCollegeTRIOStudentSupportServices

permissiontohaveaccesstomyofficialrecordsinordertocompletemyapplication.(Yourapplicationwillnot

becompletewithoutsignaturesanddates.)

 IgiveStudentSupportServices(SSS)mypermissiontoaccessmyeducationalrecordsandothermaterials

necessaryforparticipationintheSSSProgram.Furthermore,Iunderstandthatallmyrecordsarekept

confidentialandinaccordancewithOwensCommunityCollegeandFederalPrivacyLaws.

 Icertifythattheaboveinformationiscompleteandaccuratetothebestofmyknowledge.

 Igivepermissionforreleaseofmydata(name,photos,datarelatedtoawardsandachievements)forpurposeof

awards,recognitionandadvertising.

Permissiontotakemypictureforrecognitionandadvertisingpurposes: Yes

Pleasesign,dateandreturnthisform.Ifyouareconsideredadependent,asdefinedbyFreeApplicationforFederal

StudentAid(FAFSA),youmusthaveyourparent/guardiansignanddatethisform.

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.

Printstudentname:_________________________________StudentSignature:_______________________________

Date:__________________

Printparent/guardianname(ifclaimedasdependent):____________________________________________________

ParentorGuardianSignature:____________________________________________________Date:________________

3

Rev.5/2020

NEEDSASSESSMENTSURVEY

Asastudent,Iwantto:(Checkallthatapply)

 Improvegeneralstudyhabits  Improvemathskills  Improvespelling

 Improvenotetakingskills  Improvevocabulary  Reducemath/testanxiety

 Improvetimemanagementskills  Improvetesttakingskills  Developaplanforcollegecourses

 Increasecollegereadingspeed  Enhancememory  Makegoodcareerdecisions

 Improvecol

legereadingcomprehension Improvegradepointaverage Receivetransferassistance

Pleasecheckanyofthefollowingitemswhichdescribeyou:

 Outofschooltoolong  Difficultymeetingdeadlines  Panicduringtests

 Afraidoffailingincollege  Unsureofcollegeprocedures  Fewcomputerskills

 Difficultyfindingchildcare  Difficultyparticipatingindiscussions 

LimitedexperienceusingInternet

 AfraidImightnotfitinatOwens  Difficultywithpublicspeaking  Difficultymanagingmoney

 Difficultymeetingnewpeople  Difficultywithorganizing/prioritizing  Mayneedpersonalcounseling

 Notpreparedforcourselevel  Unabletou

nderstandcoursecontent Conflictwithprofessor

 Registeredfortoomanyclasses  Changedmajoroneormoretimes  Workingtoomuchduringweek



Whatobstacle(s)wouldmostlikelypreventyoufromcompletingyouracademicgoals?(Checkallthatapply)

 Poorstudyhabits  Badgrades  Familymedicalproblems

 Lackofmoney  Takethingstooseriously  Separationordivorce

 Takingthewrongclasses  Problemsathome  NoclosefriendsatOwens

 Alwaysfeelingtired  Troublesleeping  Easilydistracted

 Recurringhealthconc

erns  Afraidtospeakupinclass  Tooshy

 Alcoholand/ordrugproblems  Feelingdepressedorsad  Alwaysworrying



 Nosupportfromfamily/friends  Dealingwithbills  Testanxiety

MymostimportantareaswhichIwillneedassistanceare:(Checkallthatapply)

Financial: PersonalIssues: Transfertoa4‐yearInstitution: Career:

 PersonalBudget  StressManagement SearchProcess  Interviewing

 FAFSA  SubstanceAbuse  ApplicationProcess  Resume/CoverLetter

 Grants/Scholarships  Relationships  Funding  JobSearching

 Loans  Anxiety  Planning  Co‐op/Internship

 Depression  Transcri

pts  LeadershipDevelopment

Academic:  Motivation  Goals/Decision‐Making

 CourseSelection  ExploringDiversity

 SelectingaMajor  TimeManagement

 Practicum  Organization/Prioritization

Myskillsineachoftheareasbeloware:(Checktheappropriatebox)

Excellent AboveAverage Average Fair Poor

Math

    

Scien

ce

    

Reading

    

Writing

    

StudyStrategies

    



Describeapersonalstrengthwhichyoufeelwillhelpyoubesuccessfulasastudent:

AftergraduationfromOwensCommunityCollege,Iplanto:

4

Rev.5/2020

Note:Applyingforthisprogramisacommitmentandweexpectyoutobeanactiveparticipantwhileyou

areastudentatOwensCommunityCollege.

Ifyouareadm

ittedtoOwensCommunityCollegeTRIOStudentSupportServices,wewillrequirethefollowing 

commitmentfromyou:

• IWILLmeetwithmySSSadvisoratleasttwiceasemester.

• IWILLparticipateintu toringsessionsasneeded.

• IWILLparticipateinSSSfinancialaidandcare

erdevelopmentworkshopsandevents.

• IWILLsetgoalswithmySSSadvisorthatleadtomyplannedgraduation/transferfromOwensCommunityCollege.

CompletedapplicationsMUSTbeemailedfromanOwensCommunity

CollegeStudentemailaccount.

Nopaperapplicationswillbeacceptedatthistime.

Instructions for submission:

1. Complete all sections of the application. Application is a fillable pdf that can be

compl

ted on your computer or tablet.

Save the completed pdf file to your desktop or local drive

on your computer or tablet.

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

Return to: TRIO Student Support Services

Email:studentsupportservices@owens.edu

(Pleaseindicate“SSSApplication—STUDENTNAME”inthesubjectline)

Phone:(567)661‐7300

HowdidyoulearnaboutOwensTRIOStudentSupportServices?

 OwensStaff/Faculty:____________________Mailing/Flyer  TRIOStudent:_________________________

 E‐Mail  OwensWebsite  Other:_______________________________

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Completed 27 July 2020

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