Prairie State College-SSS

PRAIRIE STATE COLLEGE

STUDENT SUPPORT SERVICES PARTICIPANT APPLICATION

PLEASE ANSWER QUESTIONS COMPLETELY

Student Support Services
202 South Halsted Street
Chicago Heights, IL 60471
(708) 709-3500

TRIO Student Support Services is fully funded by the U.S. Department of Education.

Step 1: Student Contact Information
Name *

First MI Last
Address *

Street Address

Apt #

City State

Zip
Home Phone *
(999)999-9999
Cell Phone *
(999)999-9999
Work Phone
(999)999-9999
Email *
example@example.com
Major *

Student Demographic Information
PSC ID # *
Birthday *

Month Day Year
mm-dd-yyyy
Age *
Social Security #
999-99-9999
Gender *

Male Female
Ethnicity *

American Indian/Alaskan Native Native Hawaiian/Pacific Islander Black/African-American Latino/Hispanic White Asian

Step 3: Student Citizenship Information
Check One: *

U.S. Citizen Permanent Resident
Permanent Resident # *

Step 4: First Generation Status Information
Does your Mother have a Bachelor's (4-year college) degree? *

Yes No
Does your Father have a Bachelor's (4-year college) degree? *

Yes No
Which parent did you live with and receive support from until you were 18yrs old? (Choose One) *

Mother Only Father Only Both Mother and Father Neither Parent

Step 6: Student Financial
If you are at least 24yrs old OR answered "yes" to any of the questions in Step 5 please answer the following questions based on your personal financial information. If you are under 24yrs old and answered "no" to all of the questions in Step 5 YOUR PARENTS must provide the following information.
Total number of persons in your family? *
What was your family's taxable income (not total income) from the last calendar year? (Taxable income can be found on the federal income tax forms: IRS Form 1040 line 43 / IRS Form 1040A line 27 / IRS Form 1040 EZ line 6) *
If your family did not file a federal income tax return for last calendar year please provide your family's total income from the last calendar year. *
Taxable Income

Check Here if your family did not have any taxable income during the last calendar year.

Step 7: Student / Parent Verification
By signing this application, I attest that all the information on this application is true and accurate. Moreover, I authorize the release of the student's official academic records to Student Support Services for educational purposes including referral for financial assistance including, but not limited to scholarships, fellowships, work study, and federal financial aid.
Student Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy
Parent / Legal Guardian Signature

Clear
*Parent / Legal Guardian Signature is required if any parent/legal guardian information is included in Step 6
Date

Month Day Year
mm-dd-yyyy

Student Participant Agreement Form
Prairie State College
Student Participant Agreement Form
TRIO Student Support Services

By electing to participate in TRIO/Student Support Services, I agree to full participation as follows:
1. I will meet with my SSS advisor at least three times each semester that I am enrolled at PSC, or more as identified by my advisor throughout the school year.
2. I will attend class(es).
3. I will ask for educational support as soon as my grade falls below a "C" in any course.
4. I will attend scheduled meetings with SSS staff or will contact SSS staff to reschedule.
5. I will attend all scheduled tutoring sessions funded by the program, or will cancel by calling the TRIO Center at least 24-hours in advance.
6. I will complete and submit all required financial aid forms on time as required.
7. I will participate in appropriate SSS activities whenever possible.
8. I release authorization for the SSS program to request any and all academic and non-academic documents related to my academic progress.
9. I agree to allow the SSS program to add my Phone # to participant list to receive text messages. If no cell phone, please check box. Participants agree to inform program when phone number or address change.
Phone # *
(999)999-9999
Please check if no cell phone:

I do not have a cell phone.
If I do not comply with Items 1-8 above I might not be entitled to receive those services reserved specifically for TRIO students such as program sponsored tutoring, workshops, and cultural events.

I also understand that in order to receive the above services, I must meet the citizenship criteria and one or more of the other eligibility requirements as shown below:
1. I am a first-generation college student (neither household parent graduated with a 4-year degree). *

Yes No
2. I meet financial eligibility requirements. *

Yes No
3. I have a physical, learning or other disability. *

Yes No
4. I am a U.S. citizen or meet citizenship criteria for participation. *

Yes No
Student Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy
By accepting the student into the project, SSS agrees to provide the following:
1. Educational support services for student (identified through needs assessment).
2. Assistance in receiving and maintaining financial aid.
3. Assistance with career exploration and planning.
4. Referrals to other agencies as needed.
5. Assistance/support through SSS sponsored educational, cultural, social, and family activities.
6. College transfer assistance as needed.
SSS Coordinator Signature

Clear
Date

Month Day Year
mm-dd-yyyy
To Qualify for Services, all participants must have a documented academic need.

TRIO Student Needs Assessment
Name *

First Name Middle Last Name
Social Security No.
999-99-9999
Educational Assessment (Part 1)
Assessment Before Coming to PSC: Have you ever had your ability to read, write or do math assessed before coming to PSC? *

Yes No
Results/Outcome *
PSC Assessments: Have you ever taken assessment tests at PSC? If yes, check all that apply. *

Yes No DRP Reading NYS TABE (GED) Math CELSA English Placement Essay ESL Placement Essay
GED: Did you receive a General Equivalency Diploma? *

Yes No
Date *

Month Day Year
mm-dd-yyyy
Location *
High School: Did you graduate from high school? *

Yes No
Date *

Month Day Year
mm-dd-yyyy
Location *
Other Post Secondary *

Yes No
Where
# Hours
GPA *
Area/Major *
Were your transcripts evaluated? *

Yes No
Reason for change
College Goals: What are your educational goals? Check all that apply *

Certificate Associate Degree Transfer Bachelors Degree Undecided
Area of Study *
Comments
Educational Assessment (Part 2)

Rate yourself from 1 to 5 for each of these questions. Do you: *

	1, No, Strongly Disagree	2, Below Average, Disagree	3, OK, Average or Sometimes	4, Pretty Good, Agree	5, Yes, Strongly Agree
1. Consistently attend classes and labs?
2. Take good notes in class?
3. Have good study habits?
4. Spend enough time studying? (Fill out # Hrs/Week below)
5. Understand almost everything your instructor says?
6. Understand almost everything I read?
7. Speak well?
8. Have a good English vocabulary?
9. Write well?
10. Have good math skills?
11. Use the library to help with your studies?
12. Ask your instructor for help if you need it?
13. Ask others for help if you need it?
14. Use tutoring services when necessary?
15. Usually get good grades?

How much time to you spend studying? *
Answer the following questions:
16. Are you having problems in any of your classes? *

Yes No
Class(es) *
17. What would help you get better grades in school? *
Comments
Transer Assessment
Do you intend to transfer to another college or university? *

Yes No
Do you need transfer assistance? *

Yes No Probably in the future
Have you applied to any other colleges? *

Yes No
College(s) *
Comments
Personal Assessment
Personal
Are there personal issues in your life that may affect your ability to succeed in college? Consider issues related to yourself, family and friends. *

Yes No
Explain *
Social and Cultural
What types of activities do you enjoy? (hobbies, entertainment, sports, etc,). Explain *
What social or cultural activities would you like to participate in? *

Ethnic Events Field Trips College Visits Theater Performances Visiting Chef Dinner
Other
Are you currently involved in any clubs or organizations? *

Yes No
Which one(s)? *
Are you interested in becoming involved in any clubs or organizations at PSC? *

Yes No
Explain *
Transportation
Is transportation a problem for you? *

Yes No
Explain *
Child Care
Is childcare a problem for you? *

Yes No
Explain *
Referrals
Referrals: Would you like assistance of referrals in any of these areas: *

Yes No Child Care Housing Legal Advice Personal Counseling Transportation
Other
Are there any other issues that may make it difficult for you to succeed in college? *

Yes No
Explain *
Comments
Financial Assessment
Employment
Are you employed? *

Yes No
Hours per week *
Comments
Would you be interested in finding a different job? *

Yes No
Type of Work *
Financial Aid
Do you need financial aid? *

Yes No
Comments *
Have you ever applied for Financial Aid? *

Yes No FAFSA PSC Scholarship(s)
Semester Last Applied (FAFSA) *
Semester Last Applied (PSC Scholarship) *
Are you receiving financial aid now? *

Yes No
Type(s)? *

Pell Student Loan STS or other Grants Scholarship(s)
Other
Would you like to comment on any special circumstances affecting your financial situation? *

Yes No
Explain: *
Comments
Student Disabilities
Do you have any disability that you want us to know about? *

Yes No
Explain *
If so, have you contacted the ADA Coordinator? *

Yes No
Explain *
Have you supplied documentation to the ADA Coordinator? *

Yes No
Explain *
Comments
All Participants must have a documented academic need.

Signature
Office Use Only: Assessment completed by TRIO Coordinator

TRIO Coordinator Signature Clear
To the best of my knowledge, I agree that this Student Needs Assessment is accurate. *

Student Signature Clear
Date *

Month Day Year
mm-dd-yyyy