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
Marital Status
Location preference
Citizenship:
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:
For those individuals who are non-Hispanic/Latino, select one or more of the following:

Other
Native Language

Other
My first language is
Are you the custodial parent of dependent children?
If yes, home many?
List ages and gender
What is your educational background?
If GED, where?
Program of Study?
College?
Have you been out of school for five or more years?
Did either of your parents/guardians graduate from a four-year university?
Do you plan to earn an associate degree from MCC?
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)
Year?
Do you plan to transfer to a four-year college?
If yes, when do you plan to transfer?
Have you previously participated in a U.S. Department of education TRIO/SSS Program?
If yes, indicate when:
Location:
Program

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

Check all that apply to you:

Highest level of education completed:

Rows	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:

Rows	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

Have you applied for federal financial aid?
Have you been awarded financial aid?
For financial aid, are you to be an independent or dependent?
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