Jefferson College District Of Jefferson County-SSS-2022 Application Form

SSS Project Success Application

Additional Information
How did you find out about this program?

COL101Family MemberFriendProject SUCCESS ParticipantProject SUCCESS StaffClassroom VisitOther College Employee:Other
College Employee:

PREFERRED APPOINTMENT METHOD?
Preferred appointment method?

Virtual AppointmentIn-Person AppointmentPhone Appointment

AGREEMENT
I understand the SSS Program will use the data provided on this form to assist in assessing any academic and/or career planning needs and all information will be kept confidential according to FERPA laws. I hereby authorize the release of appropriate educational, financial aid, income, personal, disability documentation and other information as deemed necessary by the Director of Student Support Services for official use at Jefferson College.

I certify the inforomation on this application is true and accurate to the best of my knowledge.
By checking box the below, I am certifying the information I provided is true and accurate to the best of my knowledge.

By checking this box, I am certifying the information I provided is true and accurate to the best of my knowledge.
By checking the box below, I am opting out of electronic signature and request to sign this document manually.

By checking this box, I am opting out of electronic signature and request to sign this document manually.
Name

First NameLast Name
Signature

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Date

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For more information on
Project SUCCESS
call (636)481-3281 or (636)797-3000 ext. 3281,
stop by Student Center Room 217,
or visit our website at www.jeffco.edu/projectsuccess

It is the policy of Jefferson College that no person shall, on the basis of age, ancestry, color, creed, disability, genetic information, marital status, national origin, race, religion, sex, sexual orientation, or veteran status, be subject to discrimination in employment or in admission to any educational program or activity. Note: If accommodations for a disability are needed contact the Disability Support Services Office – Technology Center 101, (636) 481-3158 or 797-3000, ext. 3158 or email: dss@jeffco.edu.
Project SUCCESS is a federally-funded Student Support Services program that is awarded $306, 036 each fiscal year that operates September 1 - August 31. Student Support Services assist first-generation college students, students who are struggling to pay for college or have a documented disability that is aiming to complete a 4-year degree after their associates at Jefferson College. This grant is awarded from 2020 - 2025.

SSS Project Success Application