318263-Central Wyoming College-SSS-Application Form 2-Stephen

TRIO Student Support Services APPLICATION FORM

TRIO Student Support Services (SSS) is a federal grant program that supports students toward achieving academic success.
Demographics:
Legal Name:*

First NameMILast Name
Preferred Name:*
SSN#
999-99-9999
Local Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permanent Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
Home Phone
(999)999-9999
Work/Other Phone
(999)999-9999
Is it ok to text you*

YesNo
Email (that you check daily):*
example@example.com
Date of Birth*

MonthDayYear
mm-dd-yyyy
CWC Student ID#
Preferred Gender*

FemaleMaleNon-Binary
Ethnicity: Are you Hispanic or Latino?*

YesNo
Race (check all that apply)*

Hispanic/LatinoAmerican Indian/Alaska NativeAsian AmericanBlack/African AmericanWhiteHawaiian Native/Other Pacific Islander
Eligibility:
1. Citizenship/Residency Status
Are you a U.S. citizen?*

YesNo
If NO, from your Permanent Resident Card, please provide your USCIS*
2. Degree Status
Have you already earned an Associate’s or Bachelor’s degree?*

NoYes
If YES, stop here, not qualified!

3. First Generation College Student
a. Did your mother/caregiver receive a bachelor’s (4-yr) degree before you were 18-yrs old?*

YesNoUnknown
b. Did your father/caregiver receive a bachelor’s (4-yr) degree before you were 18-yrs old?*

YesNoUnknown
4. Will you be requesting educational and/or physical accommodations related to a disability?*

YesNo
CWC encourages individuals with disabilities to inform the Disabilities Coordinator of their needs and provide documentation at least a month prior to the beginning of each semester they plan on attending to coordinate services.
Academic Need:
Please check all that apply:*

Academic Proficiency TestsFailing GradesHigh School Equivalency (GED / HSEQ)Lack of Academic Preparedness For College Level (Struggle in Math, English or Reading)Lack of Educational and/or career goalsLimited English ProficiencyLow Admission Test Scores (ACT, COMPASS, ALEKS)Low College GradesLow High School GradesNeed for Academic / Personal Support to raise gradesOut of the Academic Pipeline for 5 or More Years
Student Information:
Is this your first year of college? (not including dual credit courses)*

YesNo
What degree would you like to obtain:*

License/CredentialAssociate’s DegreeBachelor’s DegreeMaster’s Degree +
What is your intended major?*
Do you plan to transfer to a 4-year college/university*

YesNo
Where?*
Anticipated semester & year of transfer:*
Verification and Release of Information:
I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that this information is confidential and will be used for grant purposes. I hereby authorize TRIO Student Support Services (SSS) to secure information pertinent to my participation in TRIO SSS at Central Wyoming College. This release covers, but is not limited to, access to financial aid information, educational and/or physical accommodations related to a disability verification, standardized test scores, transcripts, grade reports, and any information concerning my academic progress and performance. The TRIO SSS office will request and share this information as deemed necessary or upon student request to further student success, while remaining compliant with CWC FERPA policies.
Name*

First NameLast Name
Student Signature *

Clear
Date*

MonthDayYear
mm-dd-yyyy
TRIO Student Support Services Enrollment Agreement
My acceptance and enrollment in TRIO Student Support Services (SSS) represents
my commitment to my academic success by participating in this honorary program.
I understand that SSS staff will: monitor and communicate about my academic performance throughout each semester and inform me of programs and services offered that may be beneficial to my academic success including: grant aid, equipment loan program, advising, tutoring, enrichment workshops, completion/submission of FAFSA/Scholarships, transfer process, and mentoring program.
I understand that it is important to:
● Attend all of my classes regularly and complete all assignments on time.
● Contact my instructors and SSS staff if I have circumstances which hinder my attendance.
● Meet with an SSS staff member each semester to review my academic progress and to develop goals in a Personal Success Plan each semester.
● Keep appointments with SSS staff and tutors for support or I will call ahead of time to reschedule.
● Complete the FAFSA/Scholarship applications each year or make other financial arrangements to pay for college.
● Regularly check my CWC e-mail and complete grant required surveys.
● Seek academic and/or financial aid advice from SSS staff to register, drop and/or withdraw from courses and for transfer services.
● Participate in at least one enrichment workshop sponsored/endorsed by TRIO SSS each year.
● Notify SSS staff immediately of any changes to my name, mailing address, e-mail address, telephone number and/or academic status.
I will return equipment borrowed from TRIO SSS by the designated due date or a hold will be placed on my account as I may be financially responsible for replacement.
I have read this document and agree to the program expectations as stated above. I understand that remaining in good standing with this agreement may qualify me for additional grant aid and/or the equipment loan program.
Name*

First NameLast Name
Email*
example@example.com
Student Signature*

Clear
Date*

MonthDayYear
Date

Student Financial Aid Information*

	Yes	No
I can use the Rustler Central tab in “MyCentral” to access financial information.
I completed my FAFSA (www.studentaid.gov)
I submitted required documents to financial aid
I completed scholarship application and/or thank you letter
I know how to check CWC Rustler Central and email for financial awards
I understand my career plan and degree requirements
I have reviewed and accepted my financial aid award package and award letter

Personal Success Plan
Goals:*
My strengths are: (tasks or actions that you can do well (talents, knowledge, skills, etc.)*
My resources include: anything that will help you succeed (finances, people, materials, strategies, etc.)*
Needs or Concerns:*

Academic / Career CounselingAdapting to / uncomfortable in collegeAssistance with Financial Aid/ScholarshipsAttendanceAway from family and/or friendsCommunication SkillsComputer/Technology or Online issuesCounselingEnglish / Math / Science SkillsFamily Responsibilities / Childcare IssuesFinancial IssuesHealth / Medical IssuesHousing / Transportation IssuesLack of support from family and/or friendsSpecial Accommodation(s)Study SkillsTest AnxietyTime ManagementTransfer AssistanceTutoringUnsure of MajorVeteranWork ResponsibilitiesOther
Thank you for completing the TRIO Student Support Services Application. We look forward to seeing you at Central Wyoming College. Student Support Services staff will contact you soon after verifying your enrollment in classes at Central Wyoming College to schedule a program orientation.

Central Wyoming College TRIO Student Support Services
Main Hall Room 121, 123, 133
2660 Peck Avenue
Riverton, WY 82501
studentsupportservices@cwc.edu

TRIO Student Support Services APPLICATION FORM

Demographics:

Eligibility:

Academic Need:

Student Information:

Verification and Release of Information:

TRIO Student Support Services Enrollment Agreement

Personal Success Plan