937.328.6122 | 570 East Leel Lane, Springfield, Ohio 45505
TRIO Student Support Services
Participant Application
Completed applications may be turned into the Student Academic Support Center, Rhodes Hall, or
the 2
floor Student Services Desk, Greene Center.
Name: _______________________________________________________________________________
Last First MI
Clark State ID _______________________________
Mailing Address: ______________________________________________________________________
Street Apt# City State Zip
Cell Phone: ________-_________-_________ Home Phone: ________-_________-_________
Email Address: ___________________________________ Date of Birth: _____________________
Gender: F M
Please check one: US Citizen Permanent Resident Other
What ethnicity do you identify with (check all boxes that best describe you)?
African American/Black Caucasian/White
American-Indian or Alaska Native Hispanic or Latino
Asian Native Hawaiian or Pacific Islander
When did you graduate from high school? __________ OR Do you have a G.E.D?____________
What is your major at Clark State: _____________________________________
What level of degree do you plan to complete?
Certificate Program Associate Degree Transfer to Four-Year College
What school do you plan to transfer to? _________________________________ OR Unsure
How many credits have you completed at Clark State: ________________________________
Do you plan to attend: Full Time ¾ Time ½ Time
(per semester)
12 credits + 9- 11 credits 6-8 credits
Have you attended college before? Yes No
If yes, what school: _______________________________________
Dates attended: ___________________________________ Did you complete a degree: Yes No
Degree Program Completed: ____________________________________________________________
937.328.6122 | 570 East Leel Lane, Springfield, Ohio 45505
Have either of your parents graduated from a 4-year college? Yes No
How many people are in your household at the time of this application: __________________________
Do you have a documented disability? Yes No
Have you filed a FAFSA (financial aid form)? Yes No
Do you have access to the internet at home? Yes No
Have you participated in any of the following programs (check all that apply)?
Talent Search GEAR UP Upward Bound
Champion City Scholars TRiO SSS
Have you tested into or completed any of the following classes (check all that apply)?
College Reading Comprehension I or II College Writing Essentials or Workshop
Pre-College Math 0500/0650/0750/0700
May we contact you via text message? Yes No
How did you hear about TRIO SSS? _______________________________________________________
Release of Information
I want to participate in the TRiO Student Support Services Program. I authorize the program
Director/ representative to access my academic, financial and any other records that may be needed
for my progress monitoring and for necessary intervention. I further agree to provide, if requested
documentation to support the information stated on this form. I expect this information to be used
towards my academic and career goals and also to be kept in confidence in accordance with the
Family educational Rights and Privacy Act.
I certify that the information on this application is true and complete to the best of my knowledge.
Student Signature: ____________________________________________ Date: ___________________
TRIO SSS is a grant program funded by the United States Department of Education. All applications are
accepted and weighted according to the CSCC and DOE policy of providing educational opportunities
without regard to race, color, age, national origin, religion, sex, disability or sexual orientation.
________ Reading ________ Writing ________ Math (Pre-Algebra) ________ Elementary Algebra
Placement Test GED Out of school 5 or more years
Student is eligible for SSS participation as: FG LI DIS
Student is NOT eligible for program
Reason for ineligibility: _______________________________________________________________
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