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Ple
ase answer the following questions about yourself.
a. What is your name?
First Name Middle Initial Last Name
b. What is your mailing address?
Street Address Apt. #
City State Zip
c. What is your home phone number? ( ) -
d. What is your cell phone number ( ) -
e. Can we text you? Yes No
f. What is your personal e-mail address? @
g. What is the best way to contact you? Email Call Text
h. What is your student ID number?
i. What is your birthdate? / /
j. Are you a United States citizen or a permanent resident with a Green Card? Yes No
k. What is your gender? Female Male
a. Do you identify as Hispanic or Latino? Yes No
b. What is your ethnicity? Mark all that apply. (Please select at least one)
American Indian/Alaskan Native Native Hawaiian or Other Pacific Islander
Asian White/Caucasian
Black or African American
Please answer the following questions about yourself.
a. Highest grade completed by mother? Elementary High School Some College Received 4-yr degree
b. Highest grade completed by father? Elementary High School Some College Received 4-yr degree
c. Which parent did you regularly reside with and receive support from during your childhood (i.e.: until you were
18 years old)? (Please check only one box) ……………………………………. Both Mother Father Neither
Please answer the following questions about yourself.
a. Marital Status: Single Married Divorced/separated # of Dependents (if applicable)_________
b.
Are you receiving Financial Aid at Feather River College? ………… ........................................... Yes
No
c.
Do you receive the PELL Grant? ............................................................................................... Yes
No
Feather River College
TRiO / Student Support Services Application
(530)283-0202 EXT 221
STEP 1PERSONAL DATA
STEP 2 – ETHNIC BACKGROUND
STEP 4 – FINANCIAL INFORMATION
OFFICE USE ONLY
Status of Application:
Accepted Date ____________
Denied Date ____________
Waitlist Date ____________
Eligibility:
First Generation/Low Income
Low Income only
First Generation only
Disability/Low Income
Disability
____________________________________
Director’s Signature
____________________________________
Advisor’s Signature
STEP 3 – PARENTS INFORMATION
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Name: _____________________________________________
Please answer the following questions about yourself.
a. Are you married? ..................................................................................................................... Yes No
b. Do you have children? ............................................................................................................. Yes No
c. Are you a U.S. Armed Forces veteran? .................................................................................... Yes No
d. Are you serving on active duty in the US Armed forces? ........................................................ Yes No
e. Are/were you an orphan, in foster care, or a ward of the court? ........................................... Yes No
f. Are/were you an emancipated minor or did you have a court-appointed legal guardian? .... Yes No
g. Do you have a diagnosed disability? (Physical, learning, and/or psychological) ..................... Yes No
If yes, have you registered with the DSPS Office? ___________________________________________________
Tutoring: Math English/writing Sciences History Political Science Business Other______________
Counseling/Advising: Academic Transfer/admission Financial aid Career Personal
Academic Challenges: Study skills Time management Financial Organizational skills Stress/worrying
Personal/living environment issues Lack of support network Unclear objectives/goals
Are you currently a high school student? Yes No Did you graduate from high school? Yes No
Last High School Attended _____________________________GPA _______ Did you earn a: Diploma? or G.E.D?
I plan to earn an associate’s degree at FRC: Yes No I plan on transferring to a 4-year university: Yes No
Which four-year college(s)/universities do you intend to apply/transfer to? _____________________________________
__________________________________________________________________________________________________
What is your current major? ___________________________________________________________________________
Please list any college(s) previously attended: _____________________________________________________________
Please list any Degrees/Certificates you currently possess:
________________________________________________________
Do you participate in another a program on campus? (Check all that apply)
Football Volleyball Cross Country/Track Women’s Soccer Men’s Soccer
Softball Baseball Men’s Basketball Women’s Basketball Men’s Rodeo
Women’s Rodeo Outdoor Recreation EOPS CARE
Please read the following statement and then sign and date below it. If you (the student) are under 18, your parent or
legal guardian must also read the following statement and then sign and date below.
By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of
the student’s official academic records to the FRC TRiO/SSS program, understanding that the information in these records
will be used only to assess the student’s need for program services, discern the student’s educational progress, evaluate
the effectiveness of program activities, communicate with the student, and fulfill program-reporting requirements.
Student’s Signature Date
Signature of Student’s Parent or Legal Guardian (if student is under 18) Date
STEP 5 – BACKGROUND INFORMATION
STEP 8
STEP 9
STEP
7 – EDUCATIONAL INFORMATION
STEP 6 – SERVICES YOU MAY NEED (CHECK ALL THAT APPLY)
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