Metropolitan Community College-SSS-2021 Application Form

Metropolitan Community College – SSS – 2024 Application Form
Today's Date

MonthDayYear
MM-DD-YYYY
MCC ID #:
Name*

LastFirstFull Middle
Maiden Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
(999)999-9999
Alternate Telephone
(999)999-9999
MCC email*
Date of Birth

MonthDayYear
MM-DD-YYYY
Gender

MaleFemaleDo Not Wish to Respond
Marital Status

SingleMarriedWidowedDivorced
Location preference

Applied Technology CenterElkhom Valley CampusFort Omaha CampusFremont Area CenterSarpy CenterSouth Omaha Campus
Citizenship:

U.S. CitizenPermanent resident
Resident alien #
Furnishing the following information is not a requirement for admission and it will not be used in admission discussions. This data will be used for statistical purposes only.
Are you:

Hispanic/LatinoNon-Hispanic/Latino
For those individuals who are non-Hispanic/Latino, select one or more of the following:

American/Alaskan NativeAsianAsian-Pacific IslanderBlack or African AmericanHawaiian/Pacific IslanderNative-AmericanWhiteOther
Native Language

EnglishSpanishOther
My first language is
Are you the custodial parent of dependent children?

NoYes
If yes, home many?
List ages and gender
What is your educational background?

Recieved GEDHigh School DiplomaCurrently enrolled at MCCSome College, No College
If GED, where?
Program of Study?
College?
Have you been out of school for five or more years?

NoYes
Did either of your parents/guardians graduate from a four-year university?

NoYesNot Sure
Do you plan to earn an associate degree from MCC?

NoYes
If yes, what is your target graduation date? (quarter and year)
Do you intend to complete your degree as a full-time student? (12+ credits/quarter)

NoYes
Year?
Do you plan to transfer to a four-year college?

NoYes
If yes, when do you plan to transfer?
Have you previously participated in a U.S. Department of education TRIO/SSS Program?

NoYes
If yes, indicate when:
Location:
Program

Educational Talent SearchStudent Support ServicesUpward BoundEducational Opportunity CenterVeterans Upward BoundUpward Bound Math and Science

Qualifying for participation in the TRIO/SSS program is competitive
Provide complete, typed responses to the following questions:
What is (are) your career and four-year degree interest(s), and why are you interested in this(these) career(s) or degree(s)?
Describe your personal and academic strengths, skills and abilities.
What barriers might prevent you from being a successful college student or earning a college degree?
Disability Status
Do you have a documented physical and/or learning disability?

NoYes
If yes, are you currently receiving services from MCC’s Disability Support Services?

NoYes
Release of information

I understand that by applying for the TRIO/SSS program:
•I authorize TRIO/SSS staff to obtain records or data pertinent to my participation from other sources and to release information as required by law or the terms of the TRIO/SSS grant at MCC

•TRIO/SSS staff has my permission to communicate verbally or otherwise with MCC faculty and staff and to obtain midterm grade reports each quarter I am enrolled at MCC

•I grant Metropolitan Community College permission to release the following information to the MCC TRIO/SSS program for the purpose of academic and personal advising and program documentation requirements: academic records, financial aid records, disability documentation and statistical data from educational agencies affiliated with MCC

•I grant TRIO/SSS permission to track my past records and my future educational progress at other institutions and to release my academic and TRIO/SSS information if requested by another institution

•In consideration of acceptance of enrollment in 2024-2025 TRIO/SSS program, I authorize MCC to use my image, likeness, name and comments in, but not limited to, photographs, videos and audio recordings created or used for the purposes of publicity/marketing and advertising for the College
Initial if you would like to restrict publicity of photos:

Clear
All of the information provided under this section is true to the best of my knowledge.
Student Signature

Clear
Date

MonthDayYear
MM-DD-YYYY
Parent Signature

Clear
Date

MonthDayYear
MM-DD-YYYY
Staff Signature

Clear
Date

MonthDayYear
MM-DD-YYYY
*If you are a dependent of your parents/guardians, you must have one of them sign

Academic need and information:
Check all that apply to you:

Cumulative high school or college GPA below 2.5ACT composite score below 19 or SAT composite score below950A nontraditional college student (out of school for a minimum of five years)Completed GED or high school equivalencyCurrently failing a class or have a poor midterm gradeOne or more Fs or Ws on transcriptLimited English proficiencyLack of educational and/or career goals

Highest level of education completed:

	1	2	3	4	Degree Completed
Mother
Father
Guardian

Referral source to MCC’s TRIO/Student Support Services program

Check all that apply to you:

	Check
Academic Counseling
Personal Counseling
Selecting Courses
Preparing a resume
Interview Techniques
Applying to four-year college/university/professional schools
Obtaining internships
Faculty/staff mentoring program
Financial aid assistance
Participating in summer research programs at other universities
Academic preparedness for college-level coursework
Confidence and social skills building
General career counseling
Multicultural programs
Test-taking skills
Four-year college visits
Leadership development
Educational and/or career goal assistance
Scholarship assistance
Study/note-taking skills
Limited English proficiency
Increasing GPA
Tutoring

Taxable Income
Have you applied for federal financial aid?

NoYes
Have you been awarded financial aid?

NoYes
For financial aid, are you to be an independent or dependent?

IndependentDependent
For assistance with determining independent versus dependent status, go to: studentaid.ed.gov/students/attachments/siteresources/dependentorindependent.pdf
if independent:
The total number of exemptions claimed on your 2022 federal tax return:
Your adjusted gross income (on line 37 of 1040 return):
Your taxable income (on line 43 of 1040 return):
If dependent:
The total number of exemptions claimed on your parents’ 2022 federal tax return:
Parents’ adjusted gross income (on line 37 of 1040 return):
Parent’s taxable income (on line 43 of 1040 return)
I understand that the information on this form will be used for statistical and eligibility purposes only and held in strict confidence. All statements are true to the best of my knowledge. I will make every effort to provide TRIO/SSS with documentation of income.
Applicant Signature

Clear
Date

MonthDayYear
MM-DD-YYYY

Metropolitan Community College – SSS – 2024 Application Form