Wharton County Junior College SSS

Application Criteria
Dear Prospective Participant,

Please read this application carefully and complete all sections!

It is the sole responsibility of the applicant to ensure all required paperwork and information are received by the TRiO staff. The following documents must be turned in for an application to be considered complete:
- TRiO SSS Application
- Income Verification on Student & Parents (Tax Return 1040, Tax Return Transcript or TRiO Income Verification Worksheet)
- Completed Student Requirements
- Completed Incentive Eligibility Acknowledgement
You may submit a paper application by hand delivery or mail to the locations below or or you may submit an electronic application by scanning the QR code below or by visiting WCJC TRiO Online Application (https://botform.compansol.com/202234699414053).

Hand Delivery
STEM Success Center inside of the J.M. Hodges Library on the main campus
Monday – Friday 8:00 am – 4:00pm

Mail
Wharton County Junior College
Attn: TRiO SSS Program
911 Boling Highway
Wharton, TX 77488

Sincerely,
Jessica Falcon, TRiO SSS Program Director

Personal Information
The information provided is kept confidential and is required by the U.S. Dept. of Education to determine eligibility.
Name*

FirstMILast
Date of Birth*

MonthDayYear
mm-dd-yyyy
Social Security #*
999-99-9999
#Student ID*
@___________
Local Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
2nd Phone*
(999)999-9999
Email*
example@student.wcjc.edu
Name of Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
2nd Phone*
(999)999-9999
Email*
example@example.com

Disability Verification
Answering this question is voluntary
Do you have a documented disability? (physical, learning, and/or emotional)*

YesNo
Have/will you provide documentation of a disability to the Office of Disability Services?*

YesNoNot Applicable
Are you registered with WCJC’s Office of Disability Services?*

YesNo
Are you currently a consumer of TWC and/or THHSC?*

YesNo

Academic Needs Assessment

Educational Motivation: Please Check true or false for the following questions*

	True	False
I know how to take good notes in class.
I spend two hours studying for every hour I am in class.
I study in the library on a regular basis.
I study at home.
I must have quiet when I study.
I read my textbooks.
I prepare for class ahead of time.
I read over my notes after class.
I finish assignments on time.
I have set a goal to do well in college.
I accept responsibility for doing well in college.
It is up to my instructors whether or not I will learn in class.
Good grades are a matter of luck and timing.
When a subject is difficult for me, I study the easy parts.
I frequently wonder if school is really worthwhile for me.

Mark the box next to the statements that apply to you*

I have trouble reading college-level textbooksI have trouble taking notes from lecturesI would like to improve my grammarI am uncomfortable asking questions in classI learn best by actually doing somethingI learn best by listening to explanationsI learn best by watching something being doneI am able to research and organize a term paperI have difficulty writing papersI know when it is time to get help in a classI am uncomfortable asking for tutoringI usually get someone to help me with my classesI understand what I readI would like to increase my vocabularyI have math anxietyI have test anxietyI use a calendar to keep track of exams and quizzesI read my syllabus for each classI have difficulty concentrating

Agreement
I understand that I will be assigned either an advisor or a peer mentor and will have use of the STEM Center, and may receive advising, tutoring, study skills help, peer support, various support workshops and have access to educational support materials all at no charge once accepted into the TRiO SSS Program. I am aware that I am required to complete an updated form each semester to ensure my file remains current and to determine the nature of the services I need.

I understand that I will meet with a Student Support Services staff member a minimum of two times during each semester, and I will obtain tutoring should my grade(s) fall below a C Average. If I am on academic probation, I agree to have contact with Student Support Services at least two times a month in order to develop a plan to improve my academic standing.

I hereby give permission for Student Support Services staff to disclose and receive information concerning the nature of my Student Support Services eligibility and information concerning my academic progress on an as needed basis with appropriate faculty and staff at Wharton County Junior College. I also give TRiO SSS staff permission to view and receive any and all financial aid information from the Financial Aid Office.

My signature verifies that I have read and understood this contract, and that the information I have provided on this application is true and accurate to the best of my knowledge.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Student Requirements
To gain the full benefits of the program, I will make a commitment to my academic goals and the assistance provided. I understand that being in the TRiO Student Support Services program is a privilege and that I am ultimately responsible for my academic progress.

Please initial in the space provided to indicate acceptance. As a TRiO student participant, I agree to:
I am eligible for TRiO SSS services and incentives for the completion of ONE degree/certificate program. *
Initials
Accept and fulfill all of the TRiO SSS Student Requirements.*
Initials
Remain in good academic standing with WCJC each semester.*
Initials
Meet with my TRiO SSS Advisor a minimum of 3 times per semester to discuss academic needs.*
Initials
Participate in a minimum of 1 TRiO SSS sponsored activity each semester.*
Initials
Complete my certificate, degree and/or transfer to a 4 year institution within 3 years from acceptance into TRiO SSS.*
Initials
Create or update an academic plan (AP) with my TRiO SSS Advisor once a semester or provide my TRiO Advisor with a copy of my AP created or updated by another WCJC Advisor.*
Initials
Consult my TRiO Advisor before I make any changes to my AP such as adding, dropping or changing a class.*
Initials
Attend classes, workshops, take required tests, or other academic suggestions as recommended by my TRiO SSS Advisor.*
Initials
Return all correspondence requested by the TRiO SSS staff in a timely manner.*
Initials
Meet with a TRiO tutor on a regular basis (determined by the tutor) if I am enrolled in Math 0312. If I choose to be exempt, a waiver form must be on file with the signature of my TRiO SSS Advisor.*
Initials
Meet with a TRiO tutor on a regular basis (determined by the tutor) if I am enrolled in Math 0312. If I choose to be exempt, a waiver form must be on file with the signature of my TRiO SSS Advisor.*
Initials
Notify the TRiO SSS Clerk of any phone, address, and email changes as soon as they occur.*
Initials
Authorize the TRiO SSS staff to gather information concerning my academic progress and financial aid status prior to my participation in the program. I also grant permission to the ADA Office to release information to the TRiO SSS Program if I fall under the disability status. I understand that this information is used to help determine my eligibility for the program and is kept strictly confidential.*
Initials
Give my instructors permission to release all academic progress information to TRiO SSS staff when and if requested. If I do not meet the requirements and fulfill my academic goals, I understand that it may result in serious consequences regarding my continuation as a participant in the TRiO SSS Program.*
Initials
Strive to avoid conduct detrimental to the integrity of and public confidence in the TRiO SSS Program and WCJC.*
Initials
Permission is hereby granted to use my photograph and statements for publicity by Wharton County Junior College in press release materials, publications, advertisements, and the college’s website.*
Initials
I understand and agree to the terms outlined above and I would like the opportunity to participate in WCJC’s TRiO SSS Program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Incentive Eligibility Acknowledgement
Upon acceptance into the WCJC TRiO Student Support Services Program, I am aware that I will be eligible for incentives/resources that will help me to obtain my educational goals at WCJC as listed below.

Please initial in the space provided to indicate acknowledgment of the available FREE incentives/resources.
Up to 50 pages per day of black/white printing, no rollover pages*
Initials
Up to 50 pages per semester of color OR black/white copies, no rollover pages*
Initials
Use of the TRiO SSS Lending Library of textbooks, laptops, webcam, headphones and calculators (limited quantities & courses available)*
Initials
Access to educational materials (scantrons, school supplies, etc.) *
Initials
TRiO provided Graduation Regalia (cap/tassel, gown, & stole)
Initials
University Campus Tours (transportation & meal provided)*
Initials
Cultural Events/Activities/Trips- e.g. museum, aquarium, zoo, cultural festivals, etc. (transportation & meal provided)*
Initials
To gain the full benefits of the program, I understand that I must make a commitment to be an active program participant. I understand that being in the TRiO Student Support Services program is a privilege and that the incentives/resources are NOT required to be offered to me.

Please initial in the space provided to indicate that you understand the requirements for utilizing TRiO SSS incentives/resources.
Maintain a complete and updated TRiO SSS program file. *It is the responsibility of the student to ensure their file is complete.*
Initials
Must attend two TRiO SSS-sponsored workshops, one of which must be a financial literacy workshop.*
Initials
Must keep your TRiO SSS Advisor informed of your progress, via telephone, email, or personal contact, at least twice per semester to ensure eligibility for future incentive opportunities. *
Initials
My signature below indicates that I understand the requirements for utilizing the FREE incentives/resources offered through the TRiO SSS Program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
The TRiO SSS program reserves the right to alter, add and/or omit any services that are NOT required based on funding ability. The TRiO SSS program also reserves the right to alter, add and/or omit eligibility requirements based on required services. These rights are reserved in order to maintain compliance with regulations mandated by the U.S. Department of Education.