Entry Appt. Approval Staff
Entry Appt. Date
Processed Active Student Access
Processed ATRI In ctcLink Processed AAPI In ctcLink
Director Check In: Reportin
Exit Process Approval Processed Out ctcLink Processed SA Alum/inactive Graduation TermTRIO Year
End Status: Alumni/Inactive Director Check Out: Reportin
EDUCATIONAL GOALS (Please answer ALL questions. If you are unsure, please write “Unknown” or “Undecided”)
Degree you are seeking at Pierce College: ☐ AA DTA (Direct Transfer Degree) ☐ BUS DTA ☐ Pre-Nursing DTA ☐ BIOL DTA
☐ Associate of Science (AS-T) (Track 1 or 2) ☐ ProTech ☐ Cert Only ☐ Undecided ☐ GED ☐ HS Diploma ☐ No Degree
Pierce College Advisor/s _______________________________ Expected Pierce Graduation Date (mm/yyyy)______/________
☐ Transferring to a 4-Year BA/BS College/University/Program immediately after degree from Fort Steilacoom.
Top 3 Possible Transfer institutions 1________________________ 2 _____________________ 3 _____________________
☐ Not transferring to a 4-Year BA/BS College/University/Program immediately after 1 or 2 year degree from Pierce FS.
What careers are you interested in AND why are you interested in them? ☐ Undecided/unclear educational or career goals
What obstacles or life challenges do you see as potential barriers to your academic success?
How can our Program best support your educational goals? Please check all that apply: ☐ Career Development/Advice
☐Transfer Advice☐Academic Advice ☐Tutoring ☐Cultural Activities ☐Financial Aid Advice ☐Advocacy
☐Personal Development☐Raise GPA☐Mentoring☐Study Skills ☐STEM (Science, Tech, Engineering & Math)
☐Other _____________________________________________________________________________________________
Affidavit/Release Statement The information provided on this form is, to the best of my knowledge, accurate and true. As a TRiO Student Support
Services Program applicant, I give my permission for staff (including work-study staff) to review, obtain, or make copies of all necessary Pierce College and
prior educational documents (i.e. financial aid records, college transcripts, assessment results, statement of disability, current academic progress reports) to
determine my eligibility for the program. I also give my permission for college personnel to share information with TRiO staff as necessary to support my
educational progress and academic success. I understand that I may withdraw this consent at any time by notifying TRiO and Pierce College, in writing, of my
intent to do so. I also give my consent to share my information to outside agencies or institutions for reporting or tracking purposes, including but not limited to
the National Student Clearing House, Student Access, Department of Education, or other colleges.
Confidentiality Waiver TRiO Student Support Services staff works to provide confidentiality for students participating in our program. In addition to the limits
to confidentiality outlined above, the following waivers apply: When a student discloses that s/he knows of child or elderly abuse; when a student discloses that
s/he is a threat to self or others; when our records are legally subpoenaed. If any of the aforementioned applies, we are legally required to report our
knowledge to appropriate authorities. The mode in which the information is obtained (i.e. classroom setting, phone, electronic media, social
networking/Facebook etc., email correspondence, IM, PM, chat, text, online, or direct conversation) all carry the same responsibility of disclosure on our part.
Additionally, we want students to be conscious of the fact that our facilities structure is not designed to ensure confidentiality.
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TRiO SSS & ASPIRE are Federal grant programs which requires reporting certain information. Not providing information marked with an
†
may result in non-acceptance into a program.
*
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STUDENT’S SIGNATURE: I verify that all information provided is true and accurate _____________________________________________ DATE ___________________
PLEASE RETURN TO TRiO (WELCOME CENTER C301) - Fax 253-964-6479; Phone 253-912-3644; or email to: trio@pierce.ctc.edu
www.pierce.ctc.edu/trio TRiO SSS: Federally funded 5 year grant provided by Department of Education until August 31, 2025. (Revised 9/1/2020)
Eligibility Verification
☐ LI ☐ FG ☐ DI How was low income verified? ☐ Tax Return ☐ Statement ☐ ________________________ Verified by _____(initial)
SSS Academic Need: ☐ Academic Proficient Test ☐ Low college GPA ☐ Failing grades ☐ 5+ years out ☐ GED/HSE ☐ Low high school GPA
☐ Not college ready ☐ Lack of college/career goals ☐ Predictive indicator ☐ Lack of academic preparedness for college ☐ Support to raise GPA
How verified?
☐ Guided Self Placement Co-Rec ☐ College transcript ☐ HS transcript ☐ Student stated ☐ ________________ Verified by_______
TRiO SSS Reporting:
☐ LI-FG _____ ☐ LI Only _____ ☐ FG Only _____ ☐ LI-DI _____ ☐ DI Only _____ (initial)
Advisor Signature _________________________________ Entry Date ______________ Entry Quarter _______________ CoHort _______________
ASPIRE Reporting:
☐ AAPI _____ ☐ Non-AAPI _____ ☐ LI-FG _____ ☐ LI Only _____ ☐ FG Only _____ (initial)
Advisor Signature _________________________________ Entry Date ______________ Entry Quarter _______________ CoHort _______________
Director Verification Si
nature _________________________________ Date _____________ Student Case Number _________________
______
Revised 9/01/2020
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