Fillable Student Support Services Program Application (Green River Community College)

Fill Online, Printable, Fillable, Blank Student Support Services Program Application (Green River Community College) Form

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

Student Support Services Program Application (Green River Community College)

On average this form takes 37 minutes to complete

The Student Support Services Program Application (Green River Community College) form is 3 pages long and contains:

  • 1 signature
  • 23 check-boxes
  • 132 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Green River Community College

BROWSE GREEN RIVER 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
 
Student Support Services
Program Application
This program is funded by a US Department of Education grant that requires collecting some information about the students for whom we provide assistance. The services are
free, but we need your cooperation in providing us with the following information. This information is confidential and used only as an outline in the agreement included on the
second page of this form. Thank you.
STUDENT INFORMATION
Name:
Last First MI
Student ID Number: Pronouns:
Address:
Street City State Zip Code
Home Phone:
Cell Phone & Cell Carrier:
GRC E-mail: Secondary E-mail:
What is the best way to reach you?
Cell Phone
Text
Home Phone
Facebook *Email
*TRiO Student Support Services participants will be automatically added to the GRC TRiO SSS distribution list. TRiO will
use your GRC email for official communications, please make sure to check it regularly.
Gender: Date of Birth:
How did you hear about TRiO?
Have you participated in other TRiO Programs?
Yes
No If yes, what program?
EDUCATIONAL BACKGROUND
Have you graduated from high school?
Yes
No High School: Grad or GED Year:
Have you attended any other colleges?
Yes
No Previous college: Total Credits
Have you earned a degree?
Yes
No Name of degree:
DEMOGRAPHICS
Are you of Hispanic, Latino, or Spanish Origin? Yes No
What is your race? (you may check more
than one)
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Islander
Black or African American
Is English your primary language?
Yes
No If no, what languages do you speak?
Are you a veteran of the United States Armed Forces? Yes No
Are you, or have you ever been, in Foster Care? Yes No
Are you currently homeless?
Yes
No
**Under the Mckinney-Vento act, homeless is defined as “an individual who lacks a fixed, regular, and adequate nighttime residence, such as s living in shared housing (friends/family) due to a loss of
housing, economic hardship or similar reason, residing in emergency and transitional shelters, children/youth residing in foster care placement, sleeping in nighttime residence not ordinarily used as
regular sleeping accommodations (e.g. parks, cars, RV, tents).
Marital Status?
Single
The U.S. Department of Education funds two TRIO Student Support Services grants in the amounts of $348,002 (SSS) and $261,888 (SSS-
STEM) per year.
To receive this information in an alternative format, please contact: Disability Support Services: 253-931-6460 TDD 253-288-3359
Married
Family Household Size:
The U.S. Department of Education funds two TRIO Student Support Services grants in the amounts of $348,002 (SSS) and $261,888 (SSS-
STEM) per year.
To receive this information in an alternative format, please contact: Disability Support Services: 253-931-6460 TDD 253-288-3359
ELIGIBILITY CRITERIA
U.S. Citizen?
Yes
No If no, are you an immigrant/permanent resident?
Yes
No
When did you start at Green River College? Quarter Year
What is your program of study?
What degree are you seeking at GRC?
AA-DTA
AS-Transfer
Other
Are you planning on transferring to a four-year institution?
Yes
No
If yes, will you transfer before or after you complete your degree at GRC?
Before
After
First Generation Eligibility:
Did your mother/guardian complete a bachelor’s degree?
Yes
No
Did your father/guardian complete a bachelor’s degree?
Yes
No
Income Eligibility:
Family taxable income for last year: $ (recorded on IRS 1040 form) Family size reported:
Have you applied for financial aid?
Yes
No
If yes, are you?
Dependent or
Independent
Are you funded by:
Worker Retraining
WorkFirst
TANF
Financial Aid
Running Start
Scholarship
Self-funded
VA Benefits
Disability Eligibility:
Do you have any disability that will impact your ability to be successful?
Yes
No
Have you met with GRC’s Disability Support Services Office?
Yes
No
AFFIDAVIT, RELEASE OF INFORMATION, AND CONFIDENTIALITY STATEMENT
I certify that the information provided on this application is true and complete to the best of my knowledge. I also agree to provide
additional documentation upon request to verify the information reported.
I give TRiO-SSS staff permission to look at my college records (i.e. transcripts, financial aid applications & awards, COMPASS scores,
College Student Inventory). I understand staff may consult with other GRC staff and faculty on a quarterly basis and that all of this
information will be treated with confidentiality. I understand that this information is used to assist in the determination of my
eligibility for the program and enhance the effectiveness of the program and services provided to me. I am aware that my eligibility
and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations.
The TRiO SSS staff will work to provide privacy for students participating in the program. In addition to the limits of confidentiality
outlined above, the following waivers apply:
When a student discloses that s/he knows a child or elderly abuse
When a student discloses that s/he is a threat to self or others
When our records are legally subpoenaed
If any of the above applies, I understand that TRiO SSS is legally required to report information to the appropriate authorities. My
signature denotes my understanding of the TRiO SSS disclaimers outlined above.
Student Signature: Date:
click to sign
signature
click to edit
TRiO-SSS INITIAL ACADEMIC & SOCIAL ASSESSMENT:
Please answer the following questions. Your information will be kept private and will help us determine your needs and fit for the
TRiO program. Do not answer how you “think” you should or how you wish you were, just as how you currently feel.
Ext
remely
C
onfid
ent
Somewhat
Confident
Not
at
A
ll
C
onfid
ent
C
onfid
ent
1. How
confident
are
you in your ability to do well in
your Math classes at this institution?
2. How
confident
are
you in your ability to do well in
your
English
c
l
a
s
se
s
at this ins
tit
ution?
3. How
confident
are
you that
y
ou
w
ill
complete
your
entire program of studies and
achieve your
goals?
4. How
confident
are
you in your cultural identity?
5. How
confident
are
you in your study skills?
6. How
confident
are
you in being able to work
through times of frustration and high stress?
7. How
confident
are
you in your ability to find
campus resources?
8. How
confident
are
you in your ability to advocate
for yourself in college?
9. How
confident
are
you that
can balance school and
other commitments (work, family, friends, etc)?
10. How are you hoping TRiO-SSS will help you with to be successful in college? Why do you want to join TRiO?
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
FOR TRiO STAFF ONLY
Student Approved for Assessment: No Yes Scheduled with:
(If Application Not Approved) Student referred to other resources:
Assessment Date:
____________________
Orientation Date:
______________________
Eligibility Verified:
First Gen
Low-Income
Disability
U.S. Residency/Citizenship Seeking Trans Degree
Academic Need:
Low HS Grades
Acad Prof Tests
Failing Grades
Need for Academic Support to Raise Grades
Lack of Educational Career Goals
Low Admissions Test Scores
Low College Grades
Out of the Pipeline 5+ years
Predictive Indicator
H.S. Equivalency
Limited English Proficiency
Other:
_____________________
Lack of Academic Preparedness for College Level
Review Note:
The U.S. Department of Education funds two TRIO Student Support Services grants in the amounts of $348,002 (SSS) and $261,888 (SSS-
STEM) per year.
To receive this information in an alternative format, please contact: Disability Support Services: 253-931-6460 TDD 253-288-3359
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

Student Support Services Program Application (Green River 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 4 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document