Fillable PROGRTION Application for Participation (Midlands Technical College)

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PROGRTION Application for Participation (Midlands Technical College)

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U.S.A. forms for Midlands Technical College

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PROGRTION
Application for Participation
ASC 201 / Airport Campus / 803.822.3032 WM 236 / Beltline Campus / 803.738.7841
TRIO Student Support Services (SSS) is funded 100% by the US Department of Education and designed to assist
students toward graduation and/or transfer to a 4-year college. A student must be a citizen or permanent resident of the
US, enrolled or accepted for enrollment in an associate degree/certificate program, and meet one of the following:
* Is a first generation college student (neither parent has obtained a four-year degree); OR
* Meets US Department of Education income levels; OR
* Is registered with MTC’s Counseling and Career Services office to receive accommodations for a disability
Applicant Information
Name __________________________________________________ Student ID ____________________________
Address _______________________________________________________________________________________
City/State/Zip __________________________________________ Phone __________________________________
Date of Birth ________________________ Email _____________________________________________________
Gender: ____ Male ____ Female
Marital Status: ____ Married ____ Single ____ Separated ____ Divorced
Race (Please check all that apply):
____ American Indian or Alaskan Native ____ Asian ____ Black or African-American
____Hispanic or Latino ____ Native Hawaiian or Pacific Islander ____ White
Do you have a degree (Associate’s or Bachelor’s)? ____ Yes ____ No
Are you a U.S. Citizen? ____ Yes ____ No
Are you a Veteran? ____ Yes ____ No
Does either of your parents have a 4-year degree? ____ Yes ____ No
Household Income/Financial Aid
Student Support Services (SSS) is required to confirm applicants’ taxable income range (2018 Taxes - Form 1040,
Line 10 / 2019 Taxes – Form 1040, Line 11b). Place a check by the income range once you identify your taxable
income. If you did not have to file taxes, use “No income reported.” NOTE: If you reported parents’ income on the
FAFSA, SSS has a short, signed form you will need your parents to fill out.
Size of Family: (check one) ____ 1 ____ 2 ____ 3 ____ 4 ____ 5 ____ 6 ____ 7 ____ 8
(# living in household)
Income: (check one) ____ $19,140 or lower ____ $32,581 – $39,300 ____ $52,741 – $59,460
____ $19,141 – $25,860 ____ $39,301 -- $46,020 ____ $59,461 -- $66,180
____ $25,861 -- $32,580 ____ $46,021 -- $52,740 ____ $66,181 or higher
_____No income reported
Identify any financial aid you have: Pell Grant State Need-Based Grant LIFE Loan Other____
02/19/20 JA
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
___________________________________________ ________________________________
____________________________
Needs Assessment
(Please check off all services that apply.)
____ Academic Counseling (study tips, major, etc.) ____ Information on financial aid/scholarships
____ Personalized Advising ____ Disability Information/Referral
____ Financial Aid Counseling ____ Workshops (time management, etc.)
____ Transfer Planning ____ Cultural Enrichment Opportunities
____ Academic Mentoring ____ Information on 4-year Colleges
____ FAFSA Application Assistance ____ Assistance with 4-year college applications
Career Goals
Describe your educational/career goals.
Program of Study ___________________________________________________________________________
What are your current plans? ____ Graduate ____ Transfer to 4-year School ____ Graduate and Transfer
Release of Information
I hereby grant permission for Student Support Services to transmit and/or request any information about me for the
purpose of assistance in verifying income information, making educational decisions and in successfully completing my
educational plans. Additionally, I authorize the Counseling and Career Services office of Midlands Technical College to
verify that I have provided documentation that registers me as a student with a disability. All of your records will be kept
in confidence and in accordance with the Family Educational Rights and Privacy Act (FERPA) of 1974.
I understand the above is necessary to establish my eligibility to receive services from the program. I also understand
that completion of this application does not guarantee acceptance into the Student Support Services program.
My signature certifies that the information provided on this application is true and correct to the best of my knowledge.
Also, I agree (if requested) to provide documentation, including a copy of my (and/or parental) U.S. income tax return, to
verify the accuracy of the information given.
Student’s Signature Student ID
Date
Midlands Technical College does not discriminate in admissions or employment on the basis of race, sex, national origin or ethnic group, color,
age, religion or disability or military service. The compliance officer for Affirmative Action, Equal Employment Opportunity and Disability Action
can be reached at 803.822.3261.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Staff Use Only - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Citizen or Fin Aid Yes No Admitted and/or Enrolled Yes No Associate/Certificate Program ________ Yes No
First Generation Yes No Meets Income Level Yes No Parental/Student tax forms needed Yes No
Disability Referral Yes No MAT 101 or higher Yes No ENG 100 ________ or ENG 101/ higher _________
Hours Attempted _________ Hours Completed __________ 1
st
semester __________ SAP % ___________ CGPA ___________
FAFSA Yes No Pell Yes No Loans Yes No Other Funding ____________________ Staff Initials __________
02/19/20 JA
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PROGRTION Application for Participation (Midlands Technical College)

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Completed 4 February 2021

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