Coker University-SSS-Application Form

Student Support Services Application Packet
Student Name:*

First NameLast Name
TRIO Student Support Services (SSS) is a federally funded program of the U.S. Department of Education designed to assist students in achieving their educational goals. To qualify as an applicant, a student must be enrolled in a bachelor’s degree program at Coker University.

You must also meet at least one of the following requirements:
- Be a first-generation college student (neither parent has a four-year college degree or the custodial parent in a single-parent family does not have a four-year college degree); OR
- Meet U.S. Department of Education taxable income levels; OR
- Have a verified, documented disability of file with the accommodation’s office.

PHOTO RELASE AGREEMENT AND CONSENT
Periodically, TRIO Student Support Service Department will use pictures of student participants in printed Materials and/or the program’s webpage. I understand that such pictures will be used for the purpose of recognizing student accomplishments, documenting program events, and/or publicizing the program. I authorize Coker University and TRIO Student Support Services to use and reproduce photography(s) of me for these purposes. I further give permission for TRIO Student Support Service to include my name in such publications.*

Yes, TRIO SSS may take my photo and I give my permission for the duration that I am a participant in TRIO SSS. In giving this approval, I relinquish all rights to any advertising and/or marketing materials that may be produced containing my photograph.No, TRIO SSS may not use my photo. By checking no, I understand that my photo will not be used in advertising and/or marketing materials.
Signature:*

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Date:*

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STATEMENT OF AGREEMENT AND CONSENT
In accordance with the Family Education Rights and Privacy Act of 1974, I hereby authorize the release of my records in reference to academic transcripts, degree plans, personal assessment test scores, and other pertinent information related to my educational endeavors to the Coker University TRIO Student Support Services Program and Staff.

I hereby authorize, TRIO Student Support Services Program and Staff to transmit and/or request any information about me for the purpose of assistance in verifying eligibility, determine appropriate services, and to track my academic progress from Admissions, Academic Affairs/Faculty, Student Records, and the Office of Financial Aid. Additionally, (if applicable), I authorize Coker University Student Disability Services to verify that I have provided documentation that registers me as a student with a disability.

I understand the above is necessary to establish my eligibility to receive services from the program. I understand the Department of Education requires the submission of TRIO Student Support Services participant’s demographic, participation, and academic data. I also understand that completion of this application does not guarantee acceptance into the TRIO Student Support Services program.

I understand that I must cooperate and be an active participant by regularly attending TRIO Student Support Services sponsored activities and appointments required by the TRIO Student Support Services office.

Furthermore, I understand that failure to perform according to the program’s requirement will jeopardize my opportunities to received TRIO Student Support Services. These services include the following: (Personal and academic counseling and advising; Tutorial Assistance; Mentoring; Career Counseling and Assessment;
Workshops on study skills, note taking skills, etc.; Assistance in securing admission to a graduate university; and Cultural Enrichment and Educational Events).

My signature certifies that the information provided on this application is true and correct to the best of my knowledge. Also, I certify that all the information provided in the household income/financial aid section of this form is correct and true to the best of my knowledge. I also agree, (if requested) to provide documentation, including a copy of my (and/or parental) U.S. income tax return, to verify the accuracy of the information given.
Students’ Signature:*

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Date*

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Student Support Services Application Packet