Fillable TRIO Application FORM TRIO Application

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TRIO Application FORM TRIO Application

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File type: PDF

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Application Form
Personal Informaon
Date of Applicaon
(MM/DD/YYYY)
Social Security # Student ID#
Name 
Last First MI
Date of Birth
(MM/DD/YYYY)
Local Address 
Street/Box Number City State ZIP
Permanent Address
Street/Box Number City State ZIP
(if dierent) 
Phone # Alternate Phone # Email Address
 (   )  (   )
Gender Ethnicity/Race (please mark ALL that apply) When did you rst enroll at LCCC?
 Male
emale
 Hispanic or Lano  Black or African American
(MM/DD/YYYY)
 F  American Indian/Alaskan Nave  White
 Asian  Nave Hawaiian/Pacic Islander
Eligibility Informaon
Are you a cizen, naonal or permanent Do either of your parents have
resident of the United States?  Yes   No a four-year college degree?  Yes   No
Did you complete your FAFS ?
Are you receiving F
A  Yes   No
ederal Aid?  Yes 
t apply)
 Pell Grant 
 No
If yes, what type? (Check all tha
 SEOG   Work Study   Subsidized Loan   Unsubsidized Loan
Are you receiving addional funding?  Yes 
es, what type? 
 No
If y  Scholarships   DVR 
Do you ha
 Other:              
ve a documented disability?  Yes   No
If yes, are you working with Disability Support Services?  Yes   No
Educaonal Services
Which TRIO ser t y
/Educaonal Planning
vices interes ou? (Check all that apply)
 Academic Advising  Movaon
 Financial Aid Advising/Applicaon Assistance  P sonal Advising and Men
 Financial Literacy/budgeng
 Ac
err
er toring
 Academic esteem enhancement
ademic enhancement skills/online learning  Time Management
 Campus Ref als  Study Skills/Strategies
 Community Resources  Test-taking Skills
 Connecon to:  Working with Faculty
 Math Lab  Career Exploraon/Planning through Career Center
 Wring Center
 Tutoring
 Transfer Assistance
 Other (specify)                  
Authorizaon
I hereby cerfy that the informaon provided in this applicaon is accurate and complete to the best of my knowledge.
I hereby authorize TRIO to obtain necessary informaon from my educaonal record (e.g. transcripts, entrance/placement
test scores, grades, instructor contacts, etc). I also authorize TRIO to share informaon about me with other LCCC oces
(e.g. the DSS, Records, Counseling, Financial Aid, etc.) on a need-to-know basis in compliance with Family Educaon Rights
and Privacy Act (FERPA). If selected into TRIO, I agree to parcipate in any acvies that may be pernent to my
academic success; to work with my TRIO Advisor to develop and implement a Comprehensive Success Plan; and to
complete the terms of my TRIO Partnership Agreement.
Applicant Signature                                 Date           
Please connue to Page 3
TM
FOR OFFICE USE ONLY
Date RCVD:              
Comments:
 Orientaon complete
 Income Vericaon
 TRIO Partnership Agreement
 Assessments
 Connecon made with Career Center
 Acceptance leer sent on:            
 Added to:
 Excel
 D2L
 Colleague
 Facebook
 Blue File Folder
 Electronic Folder
 Print Prior Classes (STAC)
Eligibility/Parcipant Status/Need (Check all that apply)
 Low Income       First Generaon       Disability
Cohort Year:
Need:
 Low HS grades
 Low ACT/SAT scores
 Predicve indicator
 Academic prociency tests (Compass)
 Low college grades
 HS equivalency/GED
 Failing grades
 Out of school 5 years
 Other                           
 Limited English prociency
 Lack of educaonal or career goals
 Lack of academic prep for college
 Needs support to raise grades in required courses/major
Educaonal Background
High School: __________________________________________
Grad Year:____________________ GPA: __________________
GED Date:____________________ Score: _________________
Degree sought:   AA    AS    AAS
Major: ______________________________________________
Advisor: _____________________________________________
 Developmental Courses
Transfer College           # of Credits  GPA
Enrollment Informaon (STAT)
Currently enrolled:   FT: 12 + credits (1)    ¾: 9-11 credits (2)    ½: 6-8 credits (3)    <½: 0-5 credits (4)
Grade level at program entry:  1
st
year, never aended college – no credits aempted (1)
 1
st
year, aended before – 1 to 29 credits earned (2)
 2
nd
year – 30+ credits earned (3)
First date of enrollment at LCCC:_______________________________
LCCC credits: Aempted:____________  Earned:____________  Cumulave GPA:____________
Academic Standing:  New – no GPA  Good – 2.000 Cum GPA  Probaon – 1
st
term with Cum GPA < 2.000  Suspended
Completed by                               Date           
TRIO is funded 100% by the U.S. Department of Educaon under Title IV of the Higher Educaon Act of 1965 as amended.
PRS 3085 1/16
TM
Intake Form
Name:  Student ID#        
Please ans
                         Date:       
wer the following quesons as thoroughly and as thoughully as possible.
1. What do you do in your free me? (Hobbies, family, church, sports, etc.)
2. Are you involved with any acvies on campus?  t acvies? Yes  No If yes, wha
3. Are you currently employed?  Yes  No If yes, where do you work and for how many hours per week?
4. What is your selected program of study?
5. Do you plan to transfer to another college or university aer aending LCCC?  Yes  No 
If y
6. Wha
es, what colleges or universies are you considering?
t are your goals for this academic school year (fall through spring)?
7. What obstacles could potenally stop you from reaching your goals?
(Finances, academic diculty, home/family, employment, other?)
8. What do you hope to gain from your involvement in TRIO?
SUBMIT
PRINT
TM
Exit Form
FOR OFFICE USE ONLY
Graduaon Transfer
Graduaon Date:        Transferring to another College or University:
 Yes   No   Unsure
Degree:   AA   AS   AAS   Cercate
If Yes:   4 year   another 2-year
Program of Study:                 
School:                       
wing?   Y
Withdrawal from School
Withdra es   No
Reason:
Exit Code(s)
 Academic Dismissal (29-1)  Transferred to another 2-year instuon (30-1)
ademic dismissal (29-2) ans ear instuon (30-2) Non-ac  Tr ferred to another 4-y
 Withdrew/Did not return-Financial Reasons (29-3)  Did not Transfer OR Graduate (30-8)
 Withdrew/Did not return-Health Reasons (29-4)  Did not Transfer, not enrolled (30-9)
 Withdrew/Did not return-Academic Reasons (29-5)
 Graduated w/Cert/Diploma <2Yr Not Trans (31-1)
 Withdrew/Did not return-Personal Reasons (29-6)
 Graduated w/Cert/Diploma 2Yr Not Trans (31-2)
 Called for Military Service or deceased (29-7)
 NO degree, not enrolled, trans w/o degree (31-9)
 Graduated or Transferred (29-8)
 Graduated AA/AS Not Trans to 4Yr (31-10)
 Graduated AA/AS DID Trans to 4Yr (31-11)
 Cercate and DID Trans to 4Yr (31-12)
Exit Code(s) (from list):                                    
Comments:
Advisor:                            Date:           
Program Overview
VISION
To ensure students who are low-income, rst-generaon, and/or have a disability reach their full
academic potenal.
MISSION
TRIO Student Support Services is a federally funded program that provides collaborave and intensive
services to empower eligible LCCC students to overcome the social, economic, academic, and situaonal
barriers to obtaining accessible educaonal opportunies.
VALUES
TRIO values:
 Equal access to educaon
 Ulizing a strengths-based approach in working
with all parcipants
 Individual, academic, and personal experiences
 Cultural diversity
 Minimizing student debt
 Campus and community collaboraon
How we accomplish our mission
We provide collaborave and intensive services to help students idenfy and overcome educaonal
barriers. These services are available in individual appointments, group trainings or workshops, and
through online access. We encourage and empower our students to take ownership of their academic
eorts and successes. Our services include:
 Academic advising
 Financial aid advising and applicaon assistance
 Financial literacy
 Personal advising and mentoring
 Linking to applicable resources on campus and
within the community
 Facilitaon of career exploraon through
the Career Center
 Academic skills enhancement
 Transfer assistance
 Academic esteem enhancement
How students parcipate and what they accomplish
Students meet with their TRIO advisor on a regular basis to monitor and update their Comprehensive
Success Plan, which idenes their educaonal barriers, concerns, goals, and achievements. Students
parcipate in advising sessions, workshops, social or cultural acvies, and community service projects.
Students are retained at LCCC into their second year at a rate of 55%, will graduate at a rate of 27%
within four years, and will transfer to four-year schools at a rate of 18% within four years.
TRIO is funded 100% by the U.S. Department of Educaon under Title IV of the Higher Educaon Act of 1965 as amended.
TM
Vision
To ensure students who are low-income,
rst-generaon, and/or have a disability reach
their full academic potenal.
Mission
TRIO Student Support Services is a federally funded program that
provides collaborave and intensive services to empower eligible LCCC
students to overcome the social, economic, academic, and situaonal
barriers to obtaining accessible educaonal opportunies.
Goals
• Provide students with the knowledge and skills to be successful academically.
• Provide students with the social support to address non-cognive needs.
• Assist students in becoming informed nancial-aid-consumers.
• Assist students in transferring to four-year programs.
Outcomes
• 85% of parcipants w ill maintain good academic standing.
• 55% of parcipants will persist from one academic year to the beginning of the next and/or graduate or transfer.
• 27% of parcipants served each year will graduate from LCCC with an associate degree or cercate within 4 years.
• 18% of new parcipants served each year will receive an associate degree or cercate
and transfer to a four-year instuon within four years.
Objecves
• Develop, monitor, and complete the comprehensive success plan.
• Individual and group training to aid in academic success.
• Provide appropriate campus and community referrals.
• Financial aid educaon and assistance.
• Financial literacy.
• Transfer assistance.
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TRIO Application FORM TRIO Application

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Completed 16 February 2020

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