Fresno City College-SSS-Sam

STUDENT SUPPORT SERVICES PROGRAM

2024-2025 Application

1101 E. University Ave. Student Services Bldg. Rm. 104
Fresno, CA 93741 (559) 443-8689

Student Information
Name*

FirstMiddleLast
Who would you like to be your counselor?

Cristofer AraujoHersukhraj RaiEither one is fine
SSN
999-99-9999
Student ID #
Home Phone #
(999)999-9999
Cell Phone #
(999)999-9999
Birth Date

MonthDayYear
mm-dd-yyyy
Sex

MaleFemaleNon-binaryPrefer not to state
Gender
Mailing Address

Street Address

Apt #

CityState

Zip Code
SCCCD Email Address*
example@example.com
Personal Email Address
example@example.com
Ethnicity

American Indian or Alaskan NativeAsianBlack or African AmericanHispanic/LatinoWhiteNative Hawaiian or other Pacific IslanderOther
First Language Spoken in Home
Are you a US Citizen?

Yes, born in U.S.Yes, Permanent Resident/Non-Resident Alien
FCC TRIO SSS now accepts undocumented students.
Where is your birthplace?
If you’re not a U.S. citizen, please check your residency status below and provide a copy of your INS card:

Permanent ResidentNonresident Alien
Registration Card #
Registration Card documentation

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First Generation
Did either of your parents or guardians graduate from a four-year college?

YesNo

Please check the highest year in school/college completed by your parents or guardians

	Mother	Father
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+

Disability Status
Do you have a disability?

YesNoNot sure
If yes, please briefly describe
Are you currently receiving services from DSP&S?

YesNo

Income Eligible Information and Documentation
Did you file a Free Application for Federal Student Aid (FAFSA) for this academic year?

YesNo
Please provide a copy of your tax return with this application (if 24 years or older) or your parents/guardian tax return from the most recent tax year 2019 or 2018 federal 1040 form (1040 EZ or 1040A form). If you or your parents/guardian do not file taxes please provide proof of all other income or assistance when submitting this application.

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Please provide the following information: How much total income did you make during the last reported year.
Signature that self reported income is true and correct

Clear
Total number of people living in your household, including yourself, parent(s), siblings, or other dependents in your family
Low income (see Low Income Levels table below)

YesNoNot sure
Thank you for applying to the Student Support Services Program. Personal information collected is for reporting requirements and is confidential. Any incorrect information given on this application will affect your opportunity to receive services from SSSP. Your signature gives SSSP permission to access your financial and academic records at FCC or any other educational institutions you will attend and to consult with faculty and staff at FCC regarding your academic status.

Yes, if approved I agree to maintain a minimum of two counseling appointments and one SSSP event each semester
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
SSSP does not discriminate on the basis of national origin, religion, age, sex (gender), race, color, medical condition, ancestry, sexual orientation, marital status, physical or mental disability, or because he or she is perceived to have one or more of the foregoing characteristics.

This SSSP TRIO program is full funded by the U.S. Department of Education