Kilgore College-SSS

Kilgore College

TRIO Student Support Services-Application Form

Student Information
Student ID*
Full Name*

First NameMiddle NameLast Name
Preferred Name*

First NameLast Name
Permanent Home/Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you living on campus? If yes, what is your KC Box #?
Cell Number*
(999)999-9999
Emergency Contact Number*
(999)999-9999
KC email*
example@example.com
Personal email*
example@example.com
Birthday*

MonthDayYear
xx/xx/xxxx
Gender*
U.S. Residency Status*
Race (mark all that apply)*

AsianHispanic (select additional race)WhiteAm. Indian or Native AlaskanBlack or African Am.Native Hawaiian or Pacific Islander
First enrollment at KC*
ex:Fall 2020
Current Highest level of education*
Are you a former or current TRIO program participant? (Talent Search, Upward Bound, Gear Up,etc.)*

Yes; Former ParticipantNo; First time applicant
What program were you a former participant?
Are you a current participant in a Federal Educational Resources program (i.e., Perkins Grant)?*

YesNo
Are you currently receiving or have you applied to the Instructional Student Support program in Longview?*

YesNoApplied
What is your major?*
Do you plan to graduate from KC?*
Do you plan to transfer to a four-year university to earn a bachelor's degree?*
Please explain, in essay format, your perceived biggest barrier for not completing your higher education.*
Please explain your reasons for applying to the TRiO Program:*
1. Do you have a documented disability? (ex. Learning Disability, ADHD, Physical Disability, or Mental Health Disability, 504/ARD in school, etc.)*
Disability Documentation

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If yes, have you met with the KC Office of Disability Services to arrange accommodations?*
If yes, do you need assistance arranging accommodations?*
If yes, are you receiving services from Texas Workforce Commission or another Government agency?*
2a. What is the highest level of education obtained by your Father?*
2b. What is the highest level of education obtained by your Mother?*
Do you qualify for a Federal Pell Grant?*
Federal Pell Grant Qualification Documentation (Recent Tax Info)

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3. How familiar are you with the following?*

	Not familiar	Somewhat familiar	Very familiar
Available Support Services
Course Selection
Financial Aid warning
Academic warning
Choosing a major
Choosing a career
The transfer process

4. Please check any of the statements below that may apply to you.*

	Yes	No
Were you in foster care after age 14
Is your legal guardian someone other than your parents
Are you or have you been homeless
Were you/parent(s)recently laid off from work
Do you provide more than half financial support for children in the household
Are you married
Do you have a McKinney Vento waiver

5. Academic Need: (Please check all that apply to you)*

	Yes	No
Low high school GPA
Low college GPA
Nontraditional college student (out of school 5+years, parent, or married)
GED INSTEAD of high school diploma
Currently failing a class or have poor midterm grades
Currently on academic warning or suspension
Currently on Financial Aid warning or suspension
One or more grades of W, D, or F on transcript(s)
Limited English proficiency (ESOL)
Diagnosed and documented disability or need for special accommodations (ex. note taker or test-reader)
Low scores on a college readiness placement exam (ex. placed in developmental courses or Support Labs)
Need for academic support (poor study habits and/or test-taking skills)
Lack of education and/or career goals
Limited understanding of managing money
Need assistance with finding resources to pay for college
Involved in extracurricular activities on campus (ex. athlete, band, music, Rangerette, theater)

Agreements & Signature
Information received on this application is treated as highly confidential.
The application and any part of its contents will not be released to anyone other than program staff without a written statement from you, with the exception of secure contractual outside information management systems. Please sign below if you agree to the following:

*To fully process my application to the Kilgore College TRIO Student Support Services program I give any and all members of the Kilgore College TRIO SSS staff the permission to access my student records from the following Kilgore College entities: Data system(s), Admissions, Registrar, Financial Aid, Testing and Disability Services.
*All of the information on this application is true and accurate to the best of my knowledge. The college reserves the right to admit or deny any student enrollment in the TRiO SSS program. Completion of this application does NOT guarantee acceptance into the program.
*If accepted into the program, I agree to allow my name and/or picture to be printed in any TRiO newsletter, publication, or display (including social media) in recognition of academic success, leadership, or graduation.
*I understand that the TRiO program is federally required to report my academic status to the Dept. of Education in an Annual Performance Report, which will include my name and date of birth.
*I agree to meet with my TRiO advisor at least twice each semester and notify the program if my contact information changes or I change my academic plans.
*I give permission to discuss issues related to my academic progress and financial aid with any other college faculty and/or staff for the purpose of coordinating academic and personal support services as long as I am an active participant of the program.
*If applicable, I give permission for a TRiO staff member to review and discuss my disability documents and accommodations with the Director of Disability Services for the purpose of coordinating academic support services as long as I am an active participant of the program.
*I intend to complete my associate degree through KC within four years of acceptance into the TRiO program and immediately transfer to a four-year college or university.
*After leaving Kilgore College, I give the TRiO staff permission to use my name and birth-date to verify my enrollment through the online National Student Clearinghouse database and other Program support software systems.
By my signature, I agree to all of the above terms (use the mouse!)*

Clear