T. A. Lawson State Community College-Birmingham Campus-SSS-Application Form

Lawson State Community College-Birmingham

Student Support Services TRIO
2022 -2023 Application Year SSS

TRIO is a federally funded program
Referral by

Student Information
Legal Name (*As stated on Social Security Card or Permanent Resident ID)*

First NameMiddle Initial Last Name
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Information
Home Phone*
Cell Phone*
Cell Provider

No Cell PhoneAT&TSprintT-MobileVerizonCricketOther
LSCC Student ID #*
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*

FemaleMale
Email Address*
A12345678@lawsonstate.edu
Eligibility Information:
Citizenship Status*

U.S. CitizenPermanent Resident
*Non-U.S. Citizen Permanent Resident Status-attach copy of resident

card to SSS TRIO Application.
Did your father (or male legal guardian) earn a Bachelor’s Degree from a 4-year institution?

YesNo
Did your mother (or female legal guardian) earn a Bachelor’s Degree from a 4-year institution?

YesNo
Are you a previous SSS TRIO Student?*

YesNo
Ethnicity (Check all that apply):*

American Indian or Alaskan NativeAsianNative Hawaiian or Pacific IslanderHispanic or LatinoWhiteAfrican AmericanMore than one ethnic groupOther
Language(s) spoken in the home:

EnglishSpanishOther
Financial Aid/FAFSA:
Have you applied for FAFSA for Financial Aid?*

YesNo
Financial Information:
# of persons in your household (include self):*
Financial Status*

Dependent –claimed by parent(s) or guardian(s)Independent
- Under the age of 24
*Provide your Parent(s) or Guardian(s) SIGNED federal taxable income (form 1040, 1040A; page 1 and page 2) to SSS TRIO Office.*
- Born after January 1, 1994
- Married
- Legal dependents (ie. Children)
- Veteran (US Armed Forces)
- Orphan or a ward/dependent of the court (until age 18)
*Provide your SIGNED federal taxable income (form 1040, 1040A, 1040EZ; page 1 and page 2, if applicable) to SSS TRIO Office. $*
- If you did not file taxes, see staff for additional forms.
- If parent/guardian did not file taxes, see staff for forms
Public Assistance:
Do you or your family receive any public assistance?

YesNo
If YES, indicate type below

Food StampsAid to Families and Dependent Child(s)Temporary Assistance Needy Families (TANF)Social Security BenefitsDisability BenefitsOther
Foster Youth / Homeless / Veterans:
Are you a Foster Care Youth?

NoYes
If yes, are you receiving services through Fostering Hope?

NoYes
Are you a veteran? (*see staff for services)*

NoYes*
Are you currently homeless?

NoYes
Disability / Accommodations:
Do you have a disability?*

NoYesUnsure
If you have a Disability, do you accommodations?

YesNoIn progress
Academic Information:
Are you a high school graduate?*

NoYes
If Yes, List High School Name
If you are not H.S. Graduate, did you complete a GED?*

NoYes
If Yes, list month and year completed
If you are a recent high school graduate, do you plan on taking a Summer Course?*

NoYesMaybe
Academic History:

List ALL colleges, universities, trade or technical schools attended since high school, INCLUDING Lawson State Community College:
1) College and University Attended
1) Dates of Attendance
2) College and University Attended
2) Dates of Attendance
English Placement Test:*

I have completed the English Placement TestI have NOT completed the English Placement TestUsed scores from ACT/SAT
Math Placement Test:*

I have completed the English Placement TestI have NOT completed the English Placement TestUsed scores from ACT/SAT
Degrees/Certificates Earned:
Do you have a previous degree from another institution?*

NoYes
If Yes, please list
Transfer Information:
Which 4-year school system are you interested in applying to for transfer.*

Public-In StatePublic-Out of StatePrivate-In StatePrivate-Out of StateHistorically Black Colleges and Universities
Transfer Institutions:
1) List the 4-year school(s) you are interested in transferring to:
2) List the 4-year school(s) you are interested in transferring to:
Major(s) / Interest:
1) List the major(s) you are interested in or have decided:
2) List the major(s) you are interested in or have decided:
Which 4-year school system are you interested in applying to for transfer.

Public-In StatePublic-Out of StatePrivate-In State Private-Out of StateHistorically Black Colleges and Universities
Check List for Joining the SSS TRIO Program*

Completed SSS TRIO Program Application
Privacy Act In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are notified that the Department of Education is authorized to collect information to implement the Student Services Program under the Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties.

Disclaimer and Certification: Please initial on the lines provided that you have read and agree to each statement.*

	Initial
I authorize Student Support Services TRIO Program staff to obtain academic records or data pertinent to my participation from other departments, and programs including financial aid information prior to my participation and throughout my involvement in SSS TRIO.
I understand that if I enroll in any phase of the SSS TRIO program; I am REQUIRED to schedule and attend 3 appointments with my counselor and participate in activities (workshops, group sessions, tutoring, college tours, cultural activities, coaching, etc.) to achieve academic goals and personal growth.
If I do not follow through with my “Mutual Agreement Contract”, I will be terminated from the SSS TRIO Program and will not be able to re-enter the program.

I certify that the above information is true and correct to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature *If you are not yet 18, you must have a parent or guardian co-sign this application.*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Should be Empty: