Adirondack Community College-SSS-Application Form

SUNY Adirondack Opportunity Programs
SUNY Adirondack
640 Bay Road |Queensbury, NY 12804
Application for Participation

Personal Data
Legal Name:*

First NameMILast Name
Sex (on Gov ID):*
Preferred Name:
Date of Birth*

MonthDayYear
mm-dd-yyyy
Pronouns (Eg. She/her; He/him; They/them, etc.) :
Gender Identity: (Eg. Woman; Man; Non-binary; etc.)
Social Security Number:
999-99-9999
Student ID (Banner 500 #):*
Local 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
Home Phone Number:
(999)999-9999
Cell Phone Number:
(999)999-9999
Can we text?*

YesNo
Email:*
example@example.com
Best way to contact you:*

Cell PhoneHome PhoneEmailUS Mail
Are you Hispanic/Latino:*

YesNo
Race (Please check even if you identify and Hispanic/Latino). Options provided for sex/race/ethnicity are for federal reporting purposes only and we are unable to alter the choices provided, we understand that these options may not be all encompassing.*

Asian/East AsianSouth AsianWhiteMulti-RacialAfrican American/BlackNative American/Native Alaskan/IndigenousNative Hawaiian/other Pacific IslandersAnother not listedOther
Citizenship Status: Are you a

US CitizenPermanent Resident (Please provide copy of card)
Copy of Permanent Resident card

Browse Files

Cancelof
Residency Status: Are you a New York State Resident?*

YesNo
Are you a ward of the court?

YesNo
Are/were you in foster care as established by the court?

YesNo
Financial Status
Current Family Size:*

Family*

Total household income:*
Reported on most recent FAFSA
Biological/Adoptive Parent Education: Parent’s Education: Did either of your parents graduate from a four-year college?*

Parent 1Parent 2Neither parent has a four year college degree
Did you receive, or were you eligible to receive, Free and Reduced Price Lunch at your high school during the last (2022-23) academic year?”

YesNo

If yes, what colleges or universities?

	College/University	Dates of Attendance
1
2

Were you previously an EOP/HEOP/SEEK/College Discovery student at another institution?

YesNo

Certification
I, {main_name}, certify that the above statements are true and correct to the
best of my knowledge. I herby authorize the SUNY Adirondack TRIO Student Support Services program to verify necessary financial and academic information to determine my eligibility for services and to monitor my continued academic progress while I am a program participant. I further agree to meet with my assigned program advisor regularly and participate in regular activities.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy