Owens State Community College-SSS

TRIO STUDENT SUPPORT SERVICES APPLICATION

Per the Family Educational Rights and Privacy Act (FERPA), information in this application is confidential - we will protect your sensitive personal data. All sections of the application MUST be completed.

Incomplete applications may be returned to you or rejected.
Name*

First NameLast Name
Student ID #
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
(999)999-9999
DOB*

MonthDayYear
Date
Owens Student Email*
example@example.com

Program Eligibility
In accordance with federal regulations, a student must meet one of the following criteria to be eligible for program services:
In accordance with federal regulations, a student must meet one of the following criteria to be eligible for program services*

A first generation college student(neither parent or guardian has a Bachelor’s degree)Limitedincome (verified by an SSS staff member)Have a documented disability*
A first-generation college student (neither parent or guardian has a Bachelor’s degree)*

YesNo
Note: First-generation is defined as neither parent having a bachelors (4-year) degree. ONLY custodial parents are counted for the purposes of first-generation status. If you do not know due to being an orphan or aging out of foster care, check this box
Have a documented disability**

YesNo
*If yes, have you registered with the OCC Disability Resource Center?

YesNo

Permissions and Acknowledgements
Note: Applying for this program is a commitment and we expect you to be an active participant while you are a student at Owens Community College

If you are admitted to Owens Community College TRIO Student Support Services, we will require the following commitment from you:
- I WILL meet with my SSS advisor at least twice a semester.
- I WILL participate in tutoring sessions as needed.
- I WILL participate in SSS financial aid and career development workshops and events.
- I WILL set goals with my SSS advisor that lead to my planned graduation / transfer from Owens Community College.
In applying for a federally funded program, you should know that anyone making a false statement or misrepresentation in establishing eligibility is subject to a fine or imprisonment or both under provisions of the U.S. criminal code. By my signature, I certify that the information provided in this application is true and correct to the best of my knowledge. Additionally, I give TRIO Student Support Services (SSS) my permission to access my educational records and other materials necessary for participation in the SSS Program. Furthermore, I understand that all my records are kept confidential and in accordance with Owens Community College and Federal Privacy Laws.

Upon acceptance to the program, I agree to meet with my Academic Engagement specialist regularly, attend program activities and see a tutor regularly if enrolled in developmental courses, on Academic Warning, Dismissal, or repeating courses.
I give TRIO Student Support Services permission for release of my data (name, photos, data related to awards and achievements) for purpose of awards, recognition and advertising.*

YesNo
I give TRIO Student Support Services permission to take my picture for recognition and advertising purposes:*

YesNo
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
As a student, I want to (Check all that apply)*

Improve general study habitsImprove math skillsImprove spellingImprove note taking skillsImprove vocabularyReduce math/test anxietyImprove time management skillsImprove test taking skillsDevelop a plan for college coursesIncrease college reading speedEnhance memoryMake good career decisionsImprove college reading comprehensionImprove grade point averageReceive transfer assistance
Please check any of the following items which describe you*

Out of school too longDifficulty meeting deadlinesPanic during testsAfraid of failing in collegeUnsure of college proceduresFew computer skillsDifficulty finding child careDifficulty participating in discussionsLimited experience using InternetAfraid I might not fit in at OwensDifficulty with public speakingDifficulty managing moneyDifficulty meeting new peopleDifficulty with organizing/prioritizingMay need personal counselingNot prepared for course levelUnable to understand course contentConflict with professorRegistered for too many classesChanged major one or more timesWorking too much during week
What obstacle(s) would most likely prevent you from completing your academic goals? (Check all that apply)*

Poor study habitsBad gradesFamily medical problemsLack of moneyTake things too seriouslySeparation or divorceTaking the wrong classesProblems at homeNo close friends at OwensAlways feeling tiredTrouble sleepingEasily distractedRecurring health concernsAfraid to speak up in classToo shyAlcohol and/or drug problemsFeeling depressed or sadAlways worryingNo support from family/friendsDealing with billsTest anxiety
My most important areas which I will need assistance are (Check all that apply)
Financial*

Personal BudgetFAFSAGrants/ScholarshipsLoans
Academic*

Course SelectionSelecting a MajorPracticum
Personal Issues*

Stress ManagementSubstance AbuseRelationshipsAnxietyDepressionMotivationExploring DiversityTime ManagementOrganization/Prioritization
Transfer to a 4-year institution*

Search ProcessApplication ProcessFundingPlanningTranscripts
Career*

InterviewingResume/Cover LetterJob SearchingCo-op/InternshipLeadership DevelopmentGoals/Decision-Making

My skills in each of the areas below are (Check the appropriate box)*

	Excellent	Above Average	Average	Fair	Poor
Math
Science
Reading
Writing
Study Strategies

Describe a personal strength which you feel will help you be successful as a student.*
After graduation from Owens Community College, I plan to*
Note: Applying for this program is a commitment and we expect you to be an active participant while you are a student at Owens Community College.

If you are admitted to Owens Community College TRIO Student Support Services, we will require the following commitment from you:
- I WILL meet with my SSS advisor at least twice a semester.
- I WILL participate in tutoring sessions as needed.
- I WILL participate in SSS financial aid and career development workshops and events.
- I WILL set goals with my SSS advisor that lead to my planned graduation / transfer from Owens Community College.
Completed applications MUST include an active Owens Community College Student email account.

Instructions after submission:
1. A TRIO Student Support Services staff member will contact the applicant within 72 business hours to schedule a virtual intake interview.
  1. Virtual platform will be determined by TRIO SSS staff member.
How did you learn about Owens TRIO Student Support Services?

Owens Staff/FacultyE-MailMailing/FlyerOwens WebsiteTRIO StudentOther
If Owens Staff/Faculty or TRIO student, list their name

First NameLast Name
TRIO Student Support Services

Owens Community College

30335 Oregon Rd.

College Hall 158

Perrysburg, OH 43551

studentsupportservices@owens.edu

567.661.7300

TRIO SSS aligns with Owens Community College strategic plan Goal 1: Increasing Enrollment, Completion and Student Success, Goal 2: Improve and Enhance the Student Experience, and Goal 5: Improve College Culture and Quality of Life.

Funded by the U.S. Department of Education