* Required Student Social Security#
*1) Name_____________________________ Univ I.D.# N
Last First Middle
*2) Gender? Male Female Birth Date:
*3) Is this your first semester transferring from another college/university? Yes No
*4) Ethnicity - Hispanic/Latino: Yes No
*5) Race - Check at least one:
American Indian/Alaskan Native Asian Black or African-American White
Native Hawaiian or Other Pacific Islander
*6) Are you a citizen of the USA? Yes No If No: Country of Citizenship
Permanent Resident#
7) According to the last U.S. tax form filed, answer the following:
The number of members in the household is: ____ and the amount of taxable income is:
Do you have any physical or learning disability?
No Yes: If yes, explain:
If ‘Yes’, have you registered with the Moses Center for Students with Disabilities? No Yes
You MUST answer either question A or question B (If you have any questions, please ask).
A. If your parents are not divorced or separated, check one:
Yes, at least one of my parents have a 4 year university degree
No, neither of my parents has a 4 year university degree
B. If your parents are divorced or separated, check:
The parent I am living with has a four year university degree
Yes No
The parent I am NOT living with provides me with substantial and regular financial support
Yes No If Yes, does this parent have a 4 year degree? Yes No
How did you find out about the Office of Special Services- TRIO Program? Check One:
1. E-mail 2. My Poly 3. Mailing 4. Flyer 5. Poly Student 6. Poly Staff
7. Other (please specify):
For Office Use
_____LI & FG
____ Dis
____ Dis & LI
The Office of Special Services is primarily funded by the U.S. Department of Education, which requests the collection of
the above information for statistical purposes.
understand that the Office of Special Services has my permission to verify the information provided above and will
have access to my academic, admissions and financial aid information. *I further understand that when necessary, the
Office of Special Services staff may share information regarding students performance, adjustment, etc. with other
administrative and academic offices
Signature____________________________________ Date_______________________
Updated 7/13