Last Name *

First Name *

Date of Birth *

School ID *

Gender *

Permanent Address *

Permanent City *

Permanent State *

Permanent Zip *

Permanent Phone *

Email Address *

Institution Entry Grade Level

Race, American Indian or Alaskan Native

Race, Asian

Race, Black or African American

Race, Hawaiian or other Native to Pacific Island

Race, Hispanic

Race, White

Ethnicity

Are you a US Citizen or Permanent Resident *

Has either parent completed a four year Bachelor's Degree? *

Student Disability *

How many live in your household? *

What is your parents annual income range? *

I authorize the SSS Program to obtain, copy, review, and discuss records including:

High school transcript
Course registration for each semester
Transcripts from other colleges
Academic progress
Financial Aid records
Final grades and transcripts
Standardized test Scores
Disability Documentation

I understand the College reserves the right to admit or deny any student enrollment in the TRiO SSS program. Completion of the application does not guarantee acceptance into the program. I also certify that all of the above information is correct

I understand that if accepted I will be required to attend Orientation and meet with my Academic Coach within the first 30 days. Inability to participate may lead to dismissal from the program.

*

Please select a signature verification type.

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