Rio Hondo College SSS

Rio Hondo MESA|TRIO SSS STEM Application

Student Information
Student ID*
Full Name*

First NameMiddle (or initial)Last Name
Current Address/Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your permanent address different from this?*

YesNo
Permanent Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
(999)999-9999
Is this a cell phone?

YesNo
Secondary Phone
(999)999-9999
Preferred Email*
example@example.com
AccessRio Email
example@example.com
Birthdate*

MonthDayYear
mm-dd-yyyy
Age*
Gender

FemaleMale
Preferred Prounouns*

He/him/hisShe/her/hersThey/them/theirsOther
Race/Ethnicity (Please check all that apply)*

WhiteAsianBlack or African AmericanAmerican Indian or AlaskanNative Hawaiian/Pacific IslanderHispanic/LatinxNon-Hispanic/Latinx
Residential Status*

US CitizenF1 VisaPermanent ResidentResident AlienAB540/DACA
Resident Alien #
Attached copy

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What was your first semester and year at Rio Hondo?
Do you have an AA/AS degree?*

YesNo
Do you have an BA/BS degree?*

YesNo
Did you file a FAFSA?*

YesNo
Did you file CADAA?*

YesNo
Rio Hondo College Major
Intended Major at Transfer School
Previous school(s) attended:
High School
Grad Date
mm-yyyy

List the highest level Math and Science course you completed as a high school student

	High School Math & Science Courses	Final Grade
1
2
3

High School GPA
Educational goal (check all that apply)

TeachingMedical/Dental/Pharmacy/Optomtery/Veterinary SchoolGraduate School (Master's, PhD)
Are you employed?*

YesNo
If yes, how many hours per week?
Occupation
Are you in EOP&S?*

YesNo
Are you in TRIO SSS?*

YesNo
List other programs in which you are a participant
Highest level of education achieved by each of your parents or guardians:
Parent 1*
Parent 2*
Type of work your parents or guardian have done over the past years or prior to retiring:
Parent 1
Parent 2
Who do you currently live with?*

Parent 1Parent 2Both Parent 1 and 2Neither Parent 1 and 2Guardian(s)
Which parent did you regularly reside with and receive support from during childhood?*

Parent 1Parent 2Both Parent 1 and 2Neither Parent 1 and 2Guardian(s)

Financial Information

Answer the following questions about yourself.*

	Yes	No
a. Are you married
b. Do you have children or other dependents (other than a spouse) who receive more than half of their support from you?
c. At any time since reaching 13 years of age, where you an orphan, in foster care or a ward of the court?
d. Prior to reaching 18 years of age, were you an emancipated minor or did you have a court-appointed legal guardian?
e. Are you serving on active duty (for other than training purposes) in the U.S. Armed Forces?
f. Are you an U.S. Armed Forces veteran who was on active duty & was released under a condition other than dishonorable?
g. Are you in college and currently working on a master’s , professional or doctoral degree?
h. Are you less than 18 years of age and have no parent or guardian?
i. Are you homeless (i.e., you lack a fixed, regular & adequate nighttime residence) or are you at risk of becoming homeless?

Status
Please answer the following questions.
You and your parents must answer the following questions.
a. What is the total number of persons (including you) in your family?*
b. Check one*

We filed taxes for the previous yearOur family did not file a federal income tax return for the last calendar year. My family’s total income from last calendar year was (specify below)Our family had no taxable income during the last calendar year.
Total Income
Parent Adjusted Gross Income (1040)
Parent Taxable income (1040)
Student Adjusted Gross Income (1040)
Student Taxable income (1040)
Please upload your (student's) tax return
Please upload parents' tax return
Upload a copy of all pages of the 1040 tax form for the previous year.

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Please upload student's tax forms

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Additional documents may be required.
Please read the following statement and then date and sign below. Your parent or legal guardian must also read the following statement and then sign below.
Please read the following statement and then date and sign below.
By signing this application, I (we) attest that all the information on this application is true.

Moreover, I authorize the release of the student’s official academic records, information about performance from instructors, colleges and testing agencies, financial aid and other offices to determine eligibility to the MESA/TRiO SSS STEM Program, understanding that the information in these records will only be used to assess the student’s need for program services, discern the student’s educational progress, evaluate the effectiveness of program activities, and fulfill program-reporting requirements. You may be asked to provide additional information for eligibility determination.
I give my permission for MESA to give my name to college and employer representatives, and to use my photograph in MESA/TRiO SSS STEM and college promotional materials*

YesNo
Date

MonthDayYear
Date
Student Signature

Clear
Signature of Parent or Legal Guardian

Clear
Parent Name

First NameLast Name

Academic History
Please upload your Unofficial Rio Hondo Transcript

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Did you attend any other college/s?

YesNo
Institution Name
Please upload your unofficial college transcript

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Institution Name
Please upload your unofficial college transcript

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Institution Name
Please upload your unofficial college transcript

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