Wor Wic Community College-SSS

Wor-Wic Community College’s TRiO Student Support Services program provides services for students who are first in their family to attend college, eligible for a Pell Grant, or have a disability. The TRiO Student Support Services Center is located in Brunkhorst Hall, Room 318.

All information provided is confidential

Applicant Information
Name*

First NameLast Name
Date of Birth

MonthDayYear
mm-dd-yyyy
Cell Phone*
(999)999-9999
May we use your cell phone to send you text messages?

YesNo
Sex

MaleFemaleOther
Address*

Street Address

Apt #

CityState

Zip Code
Student ID#
Wor-Wic Email*
example@live.worwic.edu
Race/Ethnicity

American Indian/Alaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
U.S. citizen or permanent resident?*

YesNo
Permanent Resident Card #

Education
All TRiO SSS students must plan to either graduate from Wor-Wic Community College with an associate’s degree or a two-year certificate and/or transfer to a four-year university.
Previous College History
Have you attended college before?

YesNo
Total credits earned from previous college
Have you earned a college degree?*

YesNo
College/Degree
Associate's Degree/Two-year Certificate Goal
Are you planning to obtain an associate's degree or two-year certificate?

YesNo
Transfer Goal
Are you planning to transfer to a 4-year college/university?

YesNo
If so, where?
Major/Career Goal
What is your declared major?
What is your career goal?

Financial Information
Have you applied for Financial Aid by completing the FAFSA?*

YesNo
Have you received a Pell Grant?

YesNo
Do you receive any other financial assistance for college?

YesNo
If yes, please indicate below what other types of assistance you are getting.

Other grantsScholarshipsLoansWork Study

Disability Statement
It is NOT required that you complete this section of the form. HOWEVER, IF YOU DO, WE CAN ASSIST YOU WITH YOUR NEEDS.
Do you have a disability?

YesNo
If yes, please describe
Have you met with Wor-Wic Community College's Office of Disability Services Coordinator?

YesNo

Parents' Education
Does your parent have a four-year degree?
1. Parent 1?*

YesNo
2. Parent 2?

YesNo

Release of Information
I certify that the information on this application is accurate and complete to the best of my knowledge. I will provide, if requested, any documentation needed to verify this information. I hereby give TRiO Student Support Services permission to:

1. Obtain any information from my educational record that may be pertinent to my participation in the program, including information from Financial Aid, Admissions, the Registrar, Disability Services, and the National Student Clearing House.
2. Communicate with faculty regarding information to support my academic success.
3. Use my photo in TRiO SSS program and campus publications.
Name (printed)

First NameLast Name
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
If you have any questions, please contact us at 410-334-6914.

Submit
Please verify that you are human*
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