Central Arizona College offers a wide range of comprehensive services to students with a
documented disability. If you believe you would qualify for services for students with a
disability and would like more information, please place an “X” mark in the box below.
I would like more information on Student Accessibility Services
I am not interested in Student Accessibility Services at this time.
Do you have a need for assistance with learning English or do you believe your difficulty
with spoken and written English may hinder your success at Central Arizona College?
Income Status: Use 2018 Taxes to complete the 2020 FAFSA; 2018 Income below.
How many family members live in your household?
What is your family’s yearly taxable household income?
2018 Taxable income can be found on the line indicated below on each the following tax forms:
Line 43 – Tax form 1040
Line 27 – Tax form 1040A
Line 6 – Tax form 1040EZ
Did you complete the 2020 FAFSA Form?
STATEMENT OF AGREEMENT AND CONSENT:
I authorize the TRIO Student Support Services program at Central Arizona College to review my admission application, placement scores, academic record,
demographic information, financial aid reports, transcripts, and grade point average to determine my eligibility, and provide me with services which will contribute to
my success at Central Arizona College. I understand that data collected, plus the information I provide on this form, will remain confidential, and will be used for
grant reporting to the United States Department of Education.
I understand and authorize TRIO Student Support Services staff to request and share confidential information with the Student Accessibility Services program, as
well as all information related to violations and/or compliance with Central Arizona College’s Student Code of Conduct.
I authorize TRIO Student Support Services to apply for graduation on my behalf, and I understand that should I fail to pay outstanding fees, a hold may be placed on
my account at Central Arizona College. I am aware of the fact that such hold(s) will prevent me from conducting certain business with the college, which may include
the inability to access my Central Arizona College transcripts. I authorize TRIO Student Support Services to obtain tracking information for required reporting to the
United States Department of Education from the National Student Clearinghouse Student Tracker service. I authorize TRIO Student Support Services to send text
messages to the cellular phone number maintained on record with the program. Lastly, I authorize TRIO Student Support Services to obtain periodic reports from my
instructors regarding my academic progress for courses in which I am enrolled. I agree to meet with my peer and/or faculty mentor twice a month at a mutually agreed
upon time in person, via telephone, or virtually. I understand that all information will be kept confidential and will be used only for the purposes specified herein.
Parent Signature (required, even if age is 18 to 26): __________________________________
Emergency Contact Person:
Emergency Contact Person’s Relationship to You:
Return completed application to:
TRIO Student Support Services
Central Arizona College
8740 N. Overfield Road
Coolidge, Arizona 85128
Phone: (520) 494-5007 | Fax: (520) 494-5295
www.centralaz.edu/trio | Email: firstname.lastname@example.org
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