Rio Hondo College-SSS

Rio Hondo College

TRiO/S.S.S. Student Application

TO THE APPLICANT: This information helps determine your eligibility for the Student Support Services Program. All information submitted will remain confidential.

Applicant Information
Date*

MonthDayYear
mm-dd-yyyy
SID*
Name*

F NameMIL Name
SSN*
999-99-9999
DOB*

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemaleTransgender Male/Trans ManTransgender Female/Trans WomanNon-binaryGenderqueerGender non-conformingTwo-spiritOther
Address*

Street Address

Street Address Line 2

CityState

Zip
Phone*
(999)999-9999
Cell/Work*
(999)999-9999
Email*

Eligibility
If you are under the age of 24, we will need your parent's signature to verify that the self-reported income information you are providing is correct.

1. INCOME
Are you currently receiving financial aid?*

YesNo
If no, why not?
Do you receive any of the following aid? (Check all that apply)*

TANF (welfare/food stamps)GA (general assistance)SSI (supplemental security)GR (general relief)N/A

Please indicate the type and amount of income you (and/or your family) receive*

Taxable Income. For Tax Form 1040, you will find this information in Line 15.*
Total persons in your family who depend on the above total income*
2. FIRST GENERATION

Did either of your parents receive a four-year degree?
Mother*

YesNo
Father*

YesNo
3. DISABILITY
Do you have a disability?*

YesNo
Are you registered with the Disabled Students Program & Services (DSP&S) at Rio Hondo College?*

YesNo
If yes, we are required to verify your status with the DSP&S Office. Do you give the TRIO SSS Staff permission to contact the DSP&S Office to verify your registration?*

YesNo

Academic Needs Self Assessment
Check the box next to the answer that works best for you. The information you provide will be kept confidential and used only to assess student progress.

Academic Need*

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. I am satisfied with my academic grades.
2. I have good study techniques.
3. I have good note-taking skills.
4. I have no problems taking tests.
5. I have strong writing skills.
6. I am able to analyze and think critically.
7. I am good at math.
8. I know how to use computer technology.
9. I make new friends easily.
10. I feel I have good communication skills.
11. I am a good listener.
12. I am able to deal with conflict.
13. I am able to understand my emotions.
14. I know how to handle stress.
15. I know how to manage my finances.
16. Time management is easy for me.
17. I am a good problem solver.
18. I can make decisions quickly.
19. I consider myself a leader.
20. I find it easy to help others.
21. I like working in groups or teams.
22. I have high self esteem.
23. I have a plan to get to my career.
24. I volunteer on a regular basis.
25. I set goals for myself.

Certification and Signature
I certify that all information provided above is correct to the best of my knowledge and will supply the program with all required documentation if requested. I authorize the Student Support Services Program to obtain, copy, review and discuss my records for eligibility verification.

A parent signature is required if you are under the age of 24.

Exceptions: We do NOT need a parent signature if you are under the age of 24 and married, a veteran, a member of the armed forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature

Clear
Date

MonthDayYear
Date