Redlands Community College
TRIO STUDENT SUPPORT SERVICES
Student Support Services A Federal TRiO Program
1. Are you a U.S. Citizen? Yes_____; No____ Type of Verification: ___________________________________
2. Are you applying for Financial Aid (FAFSA)? Yes____; No____
a. If YES to question 2, will you be eligible for a Pell Grant? Yes____; No____
b. If YES to question 2, were you required to put your parent(s) information on the FAFSA? Yes____; No____
If you answered YES, how many people are in your parent or parents’ household (including you)? ________
(Please, submit copies of your parent’s most recent income taxes)
If you answered NO, how many people are in your household (including you)? _______
(Please, submit copies of your most recent income taxes)
3. Did EITHER of your parents graduate from a 4-year college/university? Yes_____; No_____
a. If YES, from what school? ___________________________________________________
4. Have you participated in: (Check ALL that apply)
_____Upward Bound; _____ Upward Bound Math & Science; _ ____Veterans Upward Bound
_____Talent Search; ______Educational Opportunity Center; _____Student Support Services
5. Do you have any professionally diagnosed physical or learning accommodation needs? ____Yes; ____No
a. If YES, briefly explain: ____________________________________________________________________
6. Do you plan to transfer to another school? ____Yes; ____No If yes, which one(s)? ______________________
7. Are you currently in:
Foster Care ___Yes; ___No
Homeless ___Yes; ___No
Project AIMS
Name: _________________________________________ Student ID#:________________________________
Last First MI
Sex: M____ F____ Birth Date: _____/_____/_____ Social Security #:___________________(Required)
Mailing Address: ____________________________________________________________________________
Number/Street/Apt # City State Zip
Home Address:______________________________________________________________________________
Home Phone#: (_______)_________-_________ Cell Phone (______)_____-_____________
Home Email: _______________________________School Email______________________________________
X the appropriate category: White non-Hispanic____; American Indian or Alaskan Native____;
Black non-Hispanic____; Hispanic____; Asian or Pacific Islander____; Other_________
Asian or Pacific Islander; Hispanic; Other____________
OFFICE USE ONLY
DEGREE ___________
FLAG ____________
PARTICIPANT CERTIFICATION AND CONTRACT AGREEMENT
I CERTIFY that the information I HAVE provided in applying to Trio Student Support Services is true and correct to the best of
my knowledge. I GIVE Trio SSS my permission to receive copies of my educational records and other materials necessary for
participation in the Trio SSS in accordance with the Privacy Act of 1974, all my records will be kept in confidence. I also give
permission to have any photos taken used for Trio SSS Web site, recruiting materials, and other project related activities. I
ACKNOWLEDGE that I HAVE discussed the ACADEMIC PLAN OF ACTION with Trio SSS Staff and I REALIZE that it is subject to
revision. I HAVE RECEIVED information on financial aid and I WILL PARTICIPATE in recommended Project services and activities
that will support increased success in college and improve my transferability. I AGREE to make regular contact with a Trio SSS
Staff Person.
________________________________________ ____________________________________
PARTICIPANT SIGNATURE DATE
←←←PLEASE CONTINUE TO THE BACK PAGE OF THIS APPLICATION→→→
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ACADEMIC PLAN OF ACTION
As a Project Participant I would like to take advantage of the following: (Check ALL that apply.)
LEVEL I: Trio SSS Basic Skills Courses and SSS College Courses:
____Orientation to College _____Developmental Math
____College Level Math _____College Transfer
____Psychology Seminars (Stress Management, Self-Esteem, Parenting)
Trio SSS Tutoring and Counseling and Mentors:
____Tutorial Assistance _____Personal Counseling ____Mentors
LEVEL II: Trio SSS Assistance, Advisement, Activities, and Counseling Opportunities:
____Academic Advisement _____Academic Counseling
____Career Assessment & Counseling _____Transfer Assistance
____Transfer Trips _____Cultural Activities
LEVEL III: Trio SSS Workshops and Seminars:
____ADD & ADHD _____Drugs & Alcohol
____Communication with Instructors _____Couples Communication
____Exploring Educational Alternatives _____Financial Aid/Money Management
____Human Sexuality/HIV _____Learning Skills/Study Skills
____Math Learning/Study Skills _____Parenting Skills
____Personal Growth & Relationships _____Stress & Anxiety Management
____Test Anxiety & Test Taking _____Writing & Reading Skill
____Other:___________________________________________________________
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