Kankakee Community College-SSS

Name*

First NameLast Name

Address 1

Street Address

Street Address Line 2

CityState

Zip Code

Address 2

Street Address

Street Address Line 2

CityState

Zip Code

Email*

example@example.com

Home Phone

(999)999-9999

Cell Phone

(999)999-9999

Date of Birth

mm/dd/yyyy

Gender

MaleFemale

Are you a U.S. Citizen?

YesNo

Do you have a documented disability?

YesNo

Are you planning to transfer to a 4-year college/university after graduating from KCC?

YesNo

Does your father/guardian have a Bachelor's (4-year) Degree?

YesNo

Does your mother/guardian have a Bachelor's (4-year) Degree?

YesNo

How did you learn about TRIO Student Support Services? Please select one:

Please select the support services you feel you would need and use while in the TRIO program.

Class Selection/RegistrationAssistance with applying for financial aidAssistance with applying for scholarshipsAcademic AdvisingMonitoring Academic ProgressAssistance with applying and transferring to a 4-year college

Are there any obstacles that might make it difficult for you to succeed in college? List them:

Signature

By submitting this form, I certify that the above information is correct to the best of my knowledge. I understand that this information is being provided as a matter of record; it will be kept strictly confidential. I authorize this program to obtain copies of my transcripts, test scores, financial aid awards, and other materials necessary for participation in the program. I will also grant permission for my photograph, photographic image, and/or video recorded image to be published in materials such as newsletters, annual reports, recruiting presentations, web pages, e-Profiles, etc., and release this program from any liabilities.