Fillable TRIO Student Support Services (SSS) Academic Counseling And (College of the Desert)

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TRIO Student Support Services (SSS) Academic Counseling And (College of the Desert)

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File type: PDF

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TRIO Student Support Services (SSS)
Academic Counseling and Educational Services (ACES) Application
Students who wish to participate in the TRIO SSS ACES program must complete this
application, and provide supplemental information where necessary. Potential applicants
for the program will be asked to meet with an ACES counselor to be considered for
enrollment in the program. The information you provide is strictly confidential.
Questions marked with an asterisk (*) are required. Examples of how to enter
information are provided in parenthesis (example).
Personal Information
*COD Student ID# (0999999):
*Gender: Male Female
*Date of Birth (mm/dd/yyyy):
*First Name:
*Middle Initial (enter 0 if you do not have one):
*Last Name:
Ethnicity
Native American or Alaskan Native
Asian
Black or African-American
Latino
White
Native Hawaiian or Other Pacific Islander
Other
Mailing Address
*Number and Street (43500 Monterey Ave):
*City (Cathedral City):
*State (CA):
*Zip Code (92260):
*Primary Phone Number (7609999999):
Daytime Phone Number (7609999999):
*MyCOD E-Mail Address (bbrown12345@mycod.us):
Emergency Contact
*Full Name:
*Phone Number (7609999999):
*Relationship (i.e. Parent):
Eligibility Criteria
*Check one: U.S. Citizen Permanent U.S. Resident DACA
For the ACES program eligibility requirements, a copy of your permanent resident card
with number and expiration date will be required.
*Annual Family Taxable Income
(From 1040 Income Tax Form):
*Number of Family Members Living at Home
(From 1040 Income Tax Form):
*Did you apply for Financial Aid? Yes No
*Did you receive a Pell Grant? Yes No
*Do you intend to work while attending COD? Yes No
If yes, how many hours per week?
*COD Major:
*Transfer Major:
*Have you attended a college other than COD? Yes No
If Yes, please list:
*Are you planning to earn an Associate Degree and Transfer? Yes No
Please note: If you only plan to transfer to a four-year university
or earn an Associate Degree, you will not be eligible for the
TRIO ACES program.
*Are you planning to apply to a RN or LVN program at COD before applying to transfer
to a four-year university? Yes No
Are there other programs in which you are enrolled at College of the Desert?
(check all that apply).
EOPS (If you are enrolled in
EOPS/CARE, you will not be
eligible to enroll in ACES.)
CARE
Foster Youth
DSPS
MESA
Veterans
TRIO DSPS
TRIO Veterans
DACA (not eligible for ACES)
Other
*Have you participated in a TRIO program before, such as Upward Bound (UB) or in a
TRIO program at another university or college campus?
Yes No
If yes, please list:
*I, (Print name) , certify that I am a first-
generation college student (neither of my parents or guardians with whom I reside
earned a Bachelor’s degree).
*Initials:
TRIO SSS ACES Application Personal Questionnaire
Please answer each of the following questions. You may attach additional sheets if
necessary. Questions marked with an asterisk (*) are required.
1. *How did you hear about ACES? If personal referral, please write the name.
2. *Why are you interested in becoming a participant in the ACES Program?
3. *What are your educational and career goals?
4. *Tell us about a special circumstance that may have affected your performance in
school and how you handled it (i.e., illness, family problems, discouragement, peers,
sports, etc.)
Certification
By enrolling and participating in the ACES Program at the College of the Desert, I give
my permission to the ACES Program staff to access my COD records (including those at
the Financial Aid and Admissions and Records offices) for the purposes of determining
program eligibility. By signing below, I verify that the information I have submitted on
my ACES application is true and complete to the best of my knowledge. Failure to
provide necessary documentation may be cause for denial and/or cancellation in the
Program. I also give the ACES program permission to verify the information on my
application as necessary and to monitor my academic progress while enrolled at COD.
Privacy Act
In accordance with the Privacy Act of 1974 (Public Law No. 93-579, U.S.C. 552a), you
are hereby notified that the Department of Education is authorized to collect information
to implement the Student Support Services Program under Title IV of the Higher
Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with
this authority, the Department receives and maintains personal information on
participants in the Student Support Services program. The principal purpose for
collecting this information is to administer the program, including tracking and
evaluating participant progress. Providing the information on this form, including a
social security number (SSN) is voluntary; failure to disclose a SSN will not result in the
denial of any right, benefit or privilege to which the participant is entitled. The
information that is collected on this form will be retained in the ACES program files and
may be released to other Department officials in the performance of their official duties.
*Student Signature (sign or type to sign)
:
*Date (mm/dd/yyyy):
ACES is a federally funded TRIO Student Support Services Program
ACES SSS Program
TRIO ACES Office, South Annex 12
College of the Desert
43-500 Monterey Avenue
Palm Desert, CA 92260
(760) 776-7347
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TRIO Student Support Services (SSS) Academic Counseling And (College of the Desert)

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Completed 28 July 2020

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