Pima Community College-Desert Vista-SSS

Pima Community College

New Student Application
- Legal Name:*
  
  First NameM.I.Last Name
- Preferred Name (Optional)
- Birthdate*
  
  MonthDayYear
  mm-dd-yyyy
- Address:*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Postal / Zip Code
- Cell Phone:*
  (999)999-9999
- May we Text You?*
  
  YesNo
- Alternate Phone:
  (999)999-9999
- Phone Number:
  (999)999-9999
- May we text you at this number?
  
  YesNo
- Are you comfortable completing your Intake Interview with our program virtually?
  
  YesNo
- Personal Email:*
  example@mail.com
- Student ID #: *
- Pima User Name:*
- Please select one or more of the following racial / Ethnic categories to describe yourself:*
  
  American Indian/Alaskan NativeAsianBlack or African AmericanHispanic/LatinoWhiteNative Hawaiian or Pacific Islander
- Please select the Gender associated with your social security number:*
  
  MaleFemale
- Pronouns/Gender Identity/Anything you want us to know: (Optional)
- (If any of these options do not meet your needs, please let your TRiO SSS representative know)
- Are you a U.S. Citizen or Permanent Resident?*
  
  YesNo
- Do you have a documented disability?*
  
  YesNo
- Unfortunately, based on your answer, you are not eligible for this program.
- Are you registered with the Access and Disability Resource Office (ADR)?*
  
  YesNoIn Process
- Are you a First Generation College Student?*
  
  YesNo
- A first generation college student is:
  1. An individual neither of whose parents/guardians received a Bachelor's Degree;
  
  OR
  
  2. A student who, prior to the age of 18, regularly resided with and received support from only one parent/guardian who did not receive a Bachelor's Degree.
- Are you an independent or a dependent?*
  
  I am an independent student (age 24 or older, married or emancipated; parental income is not reported on the FAFSA)I am a dependent student (younger than 24, unmarried or not emancipated; parental income is reported on the FAFSA)
- As you complete this application, which best describes you?
  
  I am 24 years or olderI am under 24, and I am completing this application with my parent/legal guardianI am under 24, but my parent/legal guardian is not currently with meI am under 24, and I am or have been an emancipated minor, a foster youth on my own, homeless, a veteran, married, or with a child and living on my own
- INDEPENDENT STUDENT SECTION:
- I am an independent student (typically age 24 or older, married or emancipated; parental income is not reported on the FAFSA) complete and sign:*
  
  YesNo
- Number of people in household:*
- Federal Taxable Income on most recent tax year:*
  Taxable Income (NOT Adjusted Gross Income: Form 1040 line 15. If taxes were not filed, please report total income from all sources.)
- Student Name:*
- Student Signature:*
  
  Clear
- Tax Year:*
- DEPENDENT STUDENT SECTION:
- I am a dependent student (younger than 24, unmarried or not emancipated; parental income is reported on the FAFSA): parent/guardians must complete and sign:*
  
  YesNo
- Number of people in household:*
- Federal Taxable Income on most recent tax year:*
  Taxable Income (NOT Adjusted Gross Income: Form 1040 line 15. If taxes were not filed, please report total income from all sources.)
- Parent/Guardian Name:*
- Parent/Guardian Signature:*
  
  Clear
- Tax Year:*
- To complete your application, we need to get income information from a parent or guardian. Provide the information below, and we will email them directly.
- Parent/Guardian full name:*
  
  First NameLast Name
- Parent/Guardian email address: *
  example@example.com
- Do you already have a Bachelor's degree?*
  
  Yes*No
- What is your intended field of study/major?*
- What are your academic plans? (Please select one)*
  
  Associate DegreeClock hour/Workforce Certificate*CertificateCourses for Recreation*Degree for TransferTransfer Credit Only*
- * If you checked any box with this symbol, you are ineligible for admittance to TRiO SSS
- Check any that apply to you. I am, or have experienced:
  
  Low high school gradesOut of school for five years or moreLow college gradesEnglish as a second languageA foster youth or emancipated minorHomelessnessUncertain about educational or career goals
- Check any that you feel you need to achieve your academic goals:*
  
  Academic AdvisingStudy SkillsCareer Development/AdvisingTutoringFinancial Aid/Financial Literacy AdvisingTransfer Advising
- I certify that all the information on this form is true and complete to the best of my knowledge. I authorize the PCC SSS Project to obtain and review any academic, financial, disability or demographic information or documentation from staff and college instructors needed for the purposes of data collection and reporting, or progress monitoring, both at the time of my application and throughout my participation in the program.
  
  I am also aware that the personal information that is provided to the Student Support Services Program will be protected under the Family Education Rights Privacy Act of 1974.
- Student Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy