Application Form

TRiO STUDENT SUPPORT SERVICES (SSS)

PARTICIPANT APPLICATION ELIGIBILITY FORM

LAWSON STATE COMMUNITY COLLEGE

BESSEMER CAMPUS

NOTE: Program participants must meet certain requirements set forth by the Department of Education. The following information will be used to determine your eligibility. All information will be held in confidence by the project staff. PLEASE COMPLETE ALL INFORMATION REQUESTED. (Incomplete applications will not be considered.)

FIRST GENERATION VERIFICATION INFORMATION
FIRST GENERATION VERIFICATION INFORMATION (PARENT(S) EDUCATION)
Does your mother (or female legal guardian) have a four-year college/university degree?*

YesNo
You do not meet the criteria for eligibility. Please contact the Director for an interview to evaluate your eligibility at 205-929-3518.
Does your father (or male legal guardian) have a four-year college/university degree?*

YesNo
You do not meet the criteria for eligibility. Please contact the Director for an interview to evaluate your eligibility at 205-929-3518.
If yes, what college/university did they graduate from?
Mother*
Father*

DISABILITY VERIFICATION
DISABILITY VERIFICATION
Do you have a documented disability?*

YesNo
You do not meet the criteria for eligibility. Please contact the Director for an interview to evaluate your eligibility at 205-929-3518.
Is the information documented with Lawson State Community College’s office of Disability Services?*

YesNo
Is the information documented with a Medical/Mental Health Professional?*

YesNo
If yes, please provide documentation from a Professional or State Rehabilitation Office*

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PROGRAM PARTICIPANT REQUIREMENTS*

	Initials
Participant agrees to strive for 100% class attendance and 100% class completion.
Participant agrees to maintain at least a 2.0 (C)
Participant agrees to contact TRiO SSS staff prior to withdrawal from classes or college.
Participant agrees to attend tutoring, counseling or other supportive services as recommended.
Participant agrees to attend mid –term evaluation sessions.
Participant agrees to participate in three (3) academic success workshops (ground/virtual).
Participant agrees to attend at least one four year university tour/cultural enrichment trip (If applicable to educational track).

I understand and agree to strive to maintain a 2.0 GPA and compete all registered classes. If at any time I experience difficulty in any of those classes, I will make an appointment with TRIO SSS staff to discuss my options and access my recourses to improve my grads(s). I will participate in any recommended supportive serves ( Tutoring, counseling, mid-term evaluation, etc.) designed to improve my college experience and academic journey. Any changes in major or withdrawals will be discussed with TRIO Staff prior to finalizing my decision. Lastly I understand and agree to participating in 3 workshops, cultural enrichment activities or college tours each semester.
Student Signature

Clear

RELEASE OF INFORMATION
RELEASE OF INFORMATION

I authorize Trio SSS staff to gather information concerning all academic and financial aid records from the school(s) I have attended or presently attend. I further authorize TRiO SSS Staff to make copies of all academic and finical aid records with the understanding that this information is used to help determine my eligibility for SSS and is kept strictly confidential.
Student Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy

IMAGE AND VOICE RELEASE
IMAGE AND VOICE RELEASE

I further authorize Trio SSS Staff to use my image and/or likeness (photos and voice) for the programs promotional purposes (brochures, videos, social media pages, printed materials, etc.)
Student Signature*

Clear
By signing above, I acknowledge that the information contained in this document is true and accurate to the best of my knowledge. My signature also further indicates that I have agreed to the above program requirements and releases (Information, image and voice).
Date Signed*

MonthDayYear
mm-dd-yyyy