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WhatisTRiOSSS? TRiO StudentSupportServices(SSS)isafederallyfunded program.Asacollegeretentionandsucces sprogram,SSS T urning oadblocks (Illinois Central College)

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TRIOisfundedbytheU. S. DepartmentofEducation RevisedJuly6,2020
IllinoisCentralCollege
Room308B
1CollegeDrive
EastPeoria,IL61635‐0001
(309)694‐8944
TRiO
=
T
urning
R
oadblocks
i
nto
O
pportunities
FundedbytheU.S.DepartmentofEducation
WhatisTRiOSSS?
StudentSupportServices(SSS)isafederallyfunded
TRiO
program.Asacollegeretentionandsucces sprogram,SSS
helpsundergraduatesmeettherigorsofhighereducationandgraduatefromICC.Theprogramisdesigned for
studentswhosesocioeconomicbackgrounds,educationalrecords,andpersonalsituationssuggesttheymay
experiencechallengesatICCthatcouldbealle viatedwithuseofresources
offeredbySSS.
WhoiseligibletoparticipateinTRiOSSS?
Eligibilityisbasedonmeetingoneofthesefederallydefinedcriteria:
Neitherparentofthestudentearnedabachelor’sdegree
Studentqualifiesforcertainlevelsoffinancialaid
Studenthasadocu mentedphysicalorlearningdisability
Also,eachSSSparticipantmustbe:
AUScitizenorpermane nt residentwhoqualifiesforfinancialaid
Admittedandenrolled,oreligibletobeenrolled,atICC
Pursuingafi rst associate’sdegree orcertificate
Committed tousing
TRiO
SSSsupporttosucceedatICC
WhenshouldIapply?
Applicationsareacceptedthroughouttheschoolyear.However,because
thenumberofopenslotsfornewstudentsislimited,itisbesttoapplyas
soonaspossible.Pleaseanswerandsignallsection softheapplication.
Yourresponsesarenecessarytodetermineprogrameligibilityandwillbe
kept100%confidential.
Whatdoestheapplicationprocessrequire?
Complete,sign,andreturntheapplicationtoRoom308B,
EastPeoriaCampus
Scheduleandcompleteaninterviewwitha
TRiO
SSSAdvisor
Receiveaconfirmationletterfromthe
TRiO
SSSProgramDirector
Attendanorientationmeetingifacceptedasa newstudent
Forhelpwiththeapplication,questions,orconcerns,pleasecallICCTRi OSSSofficeat(309)694‐8944.
AshleyGrier
TodDaniels
AdministrativeAssistant&DataSpecialist ProgramDirector
ashley.grier@icc.edutod.daniels@icc.edu
(309)694‐8944(309)694‐5275
Goto
https://icc.edu/students/student-life/trio
foraprintableapplicationonline.
LikeandfollowusonFacebookat
https://www.facebook.com/pages/category/School/TRiO-Student-Support-Services-at-ICC-324135326707/

TRIO is funded by the U.S. Department of Education Revised July 6, 2020
Illinois Central College
•
Room 308B
•
1 College Drive
•
East Peoria, IL 61635-0001
(309) 694-8944
TR
i
O
Student Support Services is a college success and persistence program that helps eligible college
students overcome the challenges of higher education and graduate from Illinois Central College.
Instructions for completing this form:
A. Read material carefully.
B. You are required to take the Academic Placement Tests.
C. Students cannot participate in program activities until all application materials are approved.
D. If you need help answering these questions, please call our office at (309) 694-8944.
E. If completing a paper copy of this form, print legibly and use black ink. Do not use pencil.
The information you provide on this form will be held in the strictest of confidence.
I. Demographic Data
ICC Student ID # __________________________
Name: __________________________________
Last First Middle
Address: ________________________________
Street
___________________________ ____ _______
City State Zip
Email : __________________________________
Home phone: _________________________
Alternate phone: _________________________
Age: ______ Birth Date: __________________
Sex:
Male
Female
Do you have a high school diploma/ GED?
Yes No
Major: ___________________ ICC GPA: _______
Ethnic Background:
Asian Black White Hispanic
Native Hawaiian/other Pacific Islander
American Indian/Alaskan Native
Total Household Size: ______________________
Are you a U.S. Citizen?
Yes No
If not, are you a permanent resident of a U.S.
territory or have you applied or do you intend to
apply for U.S. citizenship?
Yes No
II. First Generation
Have either of your parents/guardians received a
bachelor’s degree?
Yes
No
Signature:________________________________
III. Income Eligibility
If you and/or your parents filed an income tax
form, a copy of the completed form must
accompany this application.
If you and/or your parents did not file a tax form,
parents should complete the following:
I did not file a tax return for the following reason:
Received no taxable income
Taxable income received was less than the
amount required for filing a tax return.
(Submit copies of W-2 forms)
Other (Explain: ________________________)
Received non-taxable income from the
following source(s):
Social Security Benefits
Disability Benefits
TANF Benefits
Food Stamps (AFDC)
ADC Benefits
Signature:________________________________
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TRIO is funded by the U.S. Department of Education Revised July 6, 2020
IV. Disability
Are you physically challenged or learning disabled?
Yes No
If yes, please provide documentation and sign below.
Signature:_________________________________
V. Assessment Data
How did you hear about the
TRiO
SSS program?
Admissions Office
Community agency
Friends
High school staff
Upward Bound personnel
ICC staff/instructor
TRIO SSS members
Student Services Office
Other: _____________________________
•
PLEASE READ CAREFULLY BEFORE SIGNING
•
I certify that any information I have provided is true and correct to the best of my knowledge. I understand that
TRiO
Student Support Services' staff will use the data provided on this application form to assist in assessing
academic needs, and that all of the information will be kept confidential.
I do hereby consent to the release of the following information to the
TRiO
Student Support Services Program:
1. Information from the Financial Assistance Office concerning my application for an award of financial assistance.
2. All academic records that may assist the
TRiO
Student Support Services Program in determining my needs and
providing essential services.
I also understand that the
TRiO
Student Support Services staff can assist me in achieving my goals only if I fulfill my
obligation, and that failure to meet my responsibilities as required can result in suspension or termination from the
program.
Signature: _____________________________________ Date: ____________________________________
====================================
FOR OFFICE USE ONLY
==================================
The U.S. Department of Education’s approved income
limit for a family size of ______ is $_____________
The family’s verified taxable income is $____________
Therefore, the student is classified as:
1. First Generation/Low Income
2. Low Income
3. First Generation
4. Disability Only
5. Disability and Low Income
Has student applied for financial assistance?
Yes No
Is student receiving financial assistance?
Yes No
Is student’s tuition being paid by any special programs
(e.g., Peoria Promise, Workforce, etc.)?
Yes No
Academic placement tests: Yes No
Basic skills scores:
________ _________ ________
Math Reading English
Staff Signature
Date
Accepted
Denied
Director Signature
Date
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Completed 3 February 2021

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