Snead State Community College-SSS-Application Form

Part 1: Personal Data
Applicant Name*

First NameMILast Name
Address*

Street/ P.O. Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
(999)999-9999
Work Phone
(999)999-9999
Cell Phone
(999)999-9999
Snead State Email*
example@example.com
Alternate Email
example@example.com
Student A Number*
(You will be contacted through email as well as your mailing address & home phone number to notify you of upcoming events and workshops with the program.)
Gender

MaleFemale
Birth date

MonthDayYear
mm-dd-yyyy
Social Security Number
999-99-9999
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
(999)999-9999

Part 2: Ethnic Group
Ethnic Group

WhiteBlack/African-AmericanHispanic or LatinoAmerican Indian/Alaskan NativeNative Hawaiian or IslanderAsian

Part 3: Marital Status
Marital Status

SingleMarriedDivorcedSeparatedWidowed

Part 4: Citizenship
Are You a U.S. Citizen?*

YesNo
If “No”, are you a Permanent Resident or (DACA) Deferred Action for Childhood Arrivals?

YesNo
If yes, please enter your Permanent Resident Number or (DACA) Deferred Action for Childhood Arrivals Number.
Permanent Resident Number or (DACA) Deferred Action for Childhood Arrivals Number

Part 7: Disability Verification
Do you have any documented disabilities?*

YesNo
If yes, is the disability information on file with the Snead State Community College Disability Office.

YesNo
Please explain your disability.

Part 8: Financial Aid Status
Financial Aid Status*

Applied for Financial AidApproved for Financial AidNot approved for Financial Aid

Part 9: Income Verification
How many people live in your household?*
Do you or will you receive Federal Pell Grants?*

YesNo
Please indicate family/household annual Taxable Income from your last tax year
Taxable Income can be found on (Form 1040, Form 1040A, and Form 1040EZ)
By signing this form, you are verifying the federal taxable income you reported is correct to the best of your knowledge and you are giving TRIO permission to request any additional supporting documentation necessary from the SSCC Financial Aid Office.

I, {name73}, certify that my taxable income for the previous year is correct and to the best of my knowledge.
Please select:*

I certify that to the best of my knowledge I DO qualify as a Low Income Student.I certify that to the best of my knowledge I DO NOT qualify as a Low Income Student.
Documentation of Low Income Eligibility (need at least one).*

Copy of your last year Income Tax Forms or Tax Transcript.Verification of Financial Aid award letter if you receive a Pell Grant (the TRIO office can request this for you).Self-signed statement of low-income based on signature above.
Documentation

Browse Files

Cancelof
I ,{name73}, certify that the above is true to the best of my knowledge.
I, _____, certify that...

First NameLast Name

Part 10: Program Requirements
Please initial the following statements
1. Participant agrees to meet with SSS staff at least one (1) time per semester.*
Initial
2. Participant agrees to participate in a minimum of one (1) cultural/academic enrichment events per semester.*
Initial
3. Participant agrees to attend the mandatory orientation.*
Initial
4. Participant agrees to complete the (EAP) Education Action Plan with the Academic Coordinator. *
Initial

Part 12: Participant Agreement & Release of Information
As a participant in the Snead State Community College TRIO Student Support Services Program, I am committed to my education. To gain the full benefits of the program, I will make a commitment to my academic goals and the assistance provided. I understand and will STRIVE for 100% CLASS ATTENDANCE, 100% CLASS COMPLETION and A MINIMUM GRADE POINT AVERAGE OF 2.7. I authorize the TRIO Student Support Services Program staff permission to inquire and gather information concerning my academic progress such as class attendance, standardized test scores, grade point average, transcripts, tutoring, and tutoring sessions and in addition receive grade reports and financial aid status prior to my participation in the program; and I give my instructors permission to release such information to TRIO Student Support Services staff when requested. I also grant permission to the ADA Office to release information to TRIO Student Support Services if I fall under the disability status. I understand that this information is used to help determine my eligibility for the program. Should I not meet the requirements of maintaining a 2.0 or above grade point average and fulfill my academic goals, it may result in serious consequences regarding my continuation as a participant in the TRIO Student Support Services Program. I am aware that my eligibility and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations. I also agree to provide documentation upon request to verify the information reported.

I also, hereby authorize the TRIO staff to obtain a photograph for my files and the use of my photographic image in any and all publications, such as the monthly newsletter, newspaper articles, and campus-wide e-mail notices. I authorize Snead State Community College to use my name, photo, or information about me in promotion of the college through radio, television, or other printed materials. I understand that my picture could come from a digital image such as my file or from photos taken on various field trips and social events.

I am aware that personal information provided to the TRIO Student Support Services Program will be kept strictly at the highest level of confidentiality and will be protected under the Federal Education Rights & Privacy Act (FERPA) of 1974. No one will have access to the information unless they work with or for Snead State Community College and TRIO Student Support Services Program.
I, {i_____106}, certify the information provided on this form is, to the best of my knowledge, accurate and true.
I, _____, certify that...

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy

CONTACT INFORMATION

Marie Smith, TRIO Programs Director
(256) 840-4131
Email: Marie.Smith@snead.edu

Rodney Hampton,	April Harris,	Rosemary Hernandez,
Academic Coordinator	Academic Advisor	Secretary
(256) 840-4176	(256) 840-4190	(256) 571-0645
Email: Rodney.Hampton@snead.edu	Email: April.Harris@snead.edu	Email: Rosemary.Hernandez@snead.edu