Please Print Legibly:
First & Last Name:
STCC Student ID#:
Please return to: TRIO Student Support Services (SSS)
Building 19, Suite 266, 413-755-4718, ssserv@stcc.edu
Springfield Technical Community College
One Armory Square, Suite 1, P.O. Box 9000
Springfield, MA 01102-9000
Revised, 09/06/2019
Intake Interview Date:
Academic Need (circle): 1 2 3 4 5 6
Application Material Review (place a check in the box)
Intake Form with 1
generation disclosure
TRIO SSS Application
Income Documentation
ODS Self-Disclosure
Student Signature
Parent Signature (if applicable)
Intake Counselor:
7 8 9 10 11 12 13 14 15
STCC Enrollment Status (place a check in the appropriate box[es])
Currently Enrolled (enrolled this semester)
Previously Enrolled (not enrolled this semester, but returning)
Never Enrolled (New STCC or Transfer Student)
Year Student
ABE/HiSet/Gateway Grad. STCC Enroll. Date
Eligibility Determination (circle) LIF (1) LIO (2) FGO (3) DIS (4) DLI (5)
Final Interview Date:
Determination: Accepted
Not Accepted
Project Entry Date:
Date of First Service:
Director’s Signature: Date:
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Date of Application
STCC Participant Application
Date of Application:
In accordance with 20 U.S.C. § 1232g; 34 CFR Part 99, the Family Education Rights & Privacy Act (FERPA), the information provided will
be used to determine program eligibility, services needed and to evaluate participant progress. Information from this document will remain
confidential, retained in the students’ program file and used to comply with required U.S. Department of Education performance reporting.
Please print neatly, using black or blue ink
Do you have a Certificate of Completion, Associate’s Degree, Bachelor’s Degree or higher?
If yes, specify which (Certificate, Associates, Bachelors or higher):
Yes No
First Name: Last Name: M.I.
Social Security #:
Home Address (Number, Street, Apt #)
STCC Student ID:
City, State, Zip Code:
Mailing Address, City, State, Zip Code (if different from Home Address):
Primary Phone (XXX-XXX-XXXX) Circle: home
( ) --
cell other Secondary Phone (XXX-XXX-XXXX) Circle: home
( ) --
cell other
School Email Address: @ s t u d e n t . s t c c . e d u
Personal Email Address:
Gender: Male Female Date of Birth (MM-DD-YYYY):
I am a U.S. Citizen or Permanent Resident: Yes No, Alien Registration Number:
(If no, please also provide a copy of your Green Card with this application)
English is my second language: Yes, No, My primary language is:
Select one or more ethnicities that you closely identify with:
Hispanic/Latino/Latina - The Federal Government refers to Hispanic as a person of Cuban, Mexican, Puerto Rican, South or Central
American or other Spanish culture or origin, regardless of race.
American Indian/Alaska Native - American Indian/Alaskan Native refers to a person having origins in any of the original peoples of
North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian - Asian refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent,
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native Hawaiian or Other Pacific Islander - Native Hawaiian or Other Pacific Islander refers to a person having origins in any of
the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Select the race you most closely identify with Please select at least one:
Black or African American - Black or African American refers to a person having origins in any of the black racial groups of Africa.
Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American.
White - White refers to a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
First Name: Last Name: M.I.
Have you ever participated in any other TRIO or college readiness/support program (e.g. Upward Bound, Educational
Talent Search, Student Support Services, GEAR UP, etc.)?
No Yes, Which program?
Circle Yes or No
1. Yes
Were you born before Jan. 1, 1996?
2. Yes
As of today, are you married or separated, but not divorced?
3. Yes
Are you currently serving on active duty in the U.S. armed forces for purposes other than training? (If you are a
National Guard or Reserves enlistee, are you on active duty for other than state or training purposes?)
4. Yes
Are you a veteran of the U.S. armed forces?
5. Yes
Do you now have children who receive more than half of their support from you?
6. Yes
Do you have dependents (other than your children or spouse) who live with you and who receive more than half
of their support from you?
7. Yes
At any time since you turned age 13, were both your parents deceased, were you in foster care, or were you a
dependent or ward of the court?
8. Yes
Are you an emancipated minor or are you in a legal guardianship as determined by a court?
(A student in legal guardianship does not need to report parent information on the FAFSA form because he or she is
considered an independent student, but answer “No” if the court papers say “custody” rather than “guardianship.”)
9. Yes
Are you an unaccompanied youth who is homeless or self-supporting and at risk of being homeless?
(An individual is considered homeless if he or she lacks fixed, regular and adequate housing. You may be homeless if
you are living in a shelter, park, motel or car, or temporarily living with other people because you have nowhere else
to go. Also, if you are living in any of these situations and fleeing an abusive parent you may be considered homeless
when completing your FAFSA form even if your parent would provide support and a place to live).
Just like with Financial Aid, if you answered “Yes” to ANY question above, you are an independent student.
If you answered “No” to EVERY question above, you are a dependent student.
Please provide a copy of ONE of the following documents below with your completed application (check appropriate box):
(Dependent students must provide parents income information)
Most recent FAFSA Student Aid Report (SAR), signed and dated on the last page
Most recent IRS 1040 tax return, signed and dated on the last page
Most recent IRS Tax Transcript (indicating taxable income amount), signed and dated on the last page
Current Letter/Official Documentation indicating SSI benefits, Disability, etc.
Completed TRIO SSS Income Verification Form, signed and dated on the bottom of the page
Parent’s Verification and Authorization for Dependent Student to Participate in TRIO Student Support Services, if Accepted:
My signature below verifies that the information reported on the Intake form, and page 1 and 2 of this application is true and accurate to
the best of my knowledge, and that I give permission for my son/daughter to participate in the TRIO SSS program if accepted.
Parent’s Printed Name:
Parent’s Signature: Date:
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Additional Authorizations:
Photograph Release (Optional)
I hereby grant Springfield Technical Community College permission to use my likeness in any and all media, now known or
hereafter developed, throughout the world, in perpetuity, in connection with any and all editions or versions of any
promotional materials and has the exclusive right to use any promotional materials in whatever way it wishes. I understand
that I will not receive any compensation as a result of any use of my likeness as described in this release. I waive any rights
of privacy, and/or approval that I might otherwise have with regard to the use of my likeness. No use of my likeness shall be
the basis of any future claim of any kind against Springfield Technical Community College, its respective officers, directors,
agents, employees, successors or assigns, nor shall this release be made the basis of any such claim.
Signature: Date:
Authorization to Send Electronic Messages (Optional)
By signing this form, I authorize Springfield Technical Community College to send text messages to my cell phone in lieu of
phone calls, in order to convey College information, including emergency notifications. I understand that text messaging rates
will apply to any messages received from the College. I also understand that I or the College may revoke this permission in
writing at any time. I agree not to hold the College liable for any electronic messaging charges or fees generated by this
service. I further agree that in the event my contact/cell phone number changes, that I will inform the College or be liable for
any fees or charges incurred.
Privacy Disclaimer: This text message program is provided as a service to students to give important information in a timely
manner. Your information will not be sold, distributed, or in any other way shared with entities or affiliates outside of Springfield
Technical Community College
Cell phone carrier/provider: Cell phone #: ( ) -
(Example: Verizon, Boost, Sprint, T-Mobile, etc.)
Cell phone email address:
Signature: Date:
This authorization will remain in effect for the duration of my attendance at Springfield Technical Community College or until
revoked in writing by me or the College.
If you wish to decline authorization, please print “decline,and initial on the signature line.
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Follow these steps:
1. Return your application to the TRIO SSS office in Building 19, Suite 266, along with the
income documentation you selected on page 2
2. Complete the one-page Intake Form, and schedule an intake interview with a TRIO SSS
3. Once your application is complete and you have had your intake interview, schedule a
30-minute final interview with the TRIO SSS Director
We will make a decision on your application within three weeks after your final interview, and
notify you by letter (U.S. Mail) of the decision.
Questions? Contact TRIO Student Support Services at 413-755-4718