Parkland College-SSS-Application Form

Date

MonthDayYear
Date
Once we receive your application, we will contact you within two weeks to discuss the next steps in the process. Please email trio@parkland.edu or call (217) 353-2267 if you have questions.
Name*

First NameMiddle InitialLast Name
Preferred Name
Student ID Number
Enter your 7 digit student ID number
Address (local address preferred)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
(999)999-9999
Email*
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
(999)999-9999
Emergency Contact Relationship
Ethnicity (please check all that apply)

African American/BlackAmerican Indian/Alaskan NativeAsianHispanicNative Hawaiian or Pacific IslanderWhite
Gender

MaleFemaleNon-Binary
Check all the statements that are TRUE for you

I am a US Citizen, permanent citizen, or refugee.I have been admitted to Parkland College.I am a degree seeking student.I already have an associate’s or bachelor’s degree.I plan to graduate from Parkland within the next 4 years.I plan to graduate upon graduation.I am a previous college student.I have a high school diploma.I have a GED.I have been out of school for 5 or more years.I need assistance with raising a grade in one or more required course(s).I am a veteran.I am the spouse of a veteran.I am the child of a veteran.I am a concurrent or dual enrollment student.I do not know what I want to a major in and/or have no idea what career I’d like to pursue.I have taken or am currently enrolled in CCS 098, CCS 099, ENG 098, ENG 099, or any Math class below the 100 level.I am an ESL student.
I am a US citizen, permanent resident, or refugee.

YesNo
I have been admitted to Parkland College.

YesNo
I am a degree seeking student.

YesNo
I already have an associates or bachelors degree.

YesNo
I plan to graduate from Parkland within the next 4 years.

YesNo
I plan to transfer upon graduation.

YesNo
I am a previous college student.

YesNo
I have a high school diploma.

YesNo
I have a GED or State High School Diploma equivalent.

YesNo
I have been out of school for 5 or more years.

YesNo
I need assistance with raising a grade in one or more required course(s).

YesNo
I am a veteran.

YesNo
I am the spouse of a veteran.

YesNo
I am the child of a veteran.

YesNo
I am a concurrent or dual enrollment student.

YesNo
I do not know what I want to a major in and/or have no idea what career I’d like to pursue.

YesNo
I have taken or am currently enrolled in CCS 098, CCS 099, ENG 098, ENG 099, or any Math class below the 100 level.

YesNo
I am an ESL student.

YesNo
Please select one of the options below

My parents/guardians did not graduate from a 4-year university.Prior to the age of 18, I did not live with my parents.Prior to the age of 18, I only lived with one parent who did not graduate from a 4-year university.I am a ward of the state, was in foster care, or considered to have been a homeless youth.At least one parent/guardian who I regularly lived with has a bachelor's degree (4-year degree).
Completion of this section is optional but very helpful in establishing your elibility for the TRiO program.
Accessibility Service Registration: I am registered with Parkland's Office of Accessibility Serivces (U260).

YesNo
By selecting yes, I give permission for the Office of Accessibility Services to verify the information disclosed to the TRiO director for auditing purposes. Note – Your accessibility information is confidential and will remain on file only in the Office of Accessibility Services. However, the TRiO staff must verify your status as a student with documentation for auditing purposes. For additional information on accommodations, call 217/353-2338.
This section is designed to determine if you meet the income guidelines to become a program participant. You will need to use the following chart to determine financial need for the program. You will need to know whether you are an independent or dependent student.
- To qualify as an independent student, you must meet one of the below qualifications.
  - I am 24 years old or older.
  - I have been an orphan, in foster care, or ward of the court after age 13.
  - I am married, separated, or divorced.
  - I have at least one child who receives more that half their support from me.
  - I am a homeless person or an unaccompanied youth.
  - I am a veteran of the Armed Forces or am currently serving on active duty.
  - I am an emancipated minor or in a legal guardianship.
  - I have been determined to be an independent student by Parkland’s financial aid office.
Are you an independent student?

Yes (skip to Independent student section)No

If you are not an independent student, you are dependent student and you will need your parents to fill out the information below.
If you need assistance regarding this application, please call the TRiO office 217/353-2267 and speak with a staff member.

Federal TRiO Programs Income Chart (effective January 11, 2024 until further notice)

Size of Family Unit	48 contiguous States, DC, and Outlying Jurisdictions	Alaska	Hawaii
1	$22,590	$28,215	$25,965
2	$30,660	$38,310	$35,250
3	$38,730	$48,405	$44,535
4	$46,800	$58,500	$53,820
5	$54,470	$68,595	$63,105
6	$62,940	$78,690	$72,390
7	$71,010	$88,785	$81,675
8	$79,080	$98,880	$90,960

For family units with more than eight members, add the following amount for each additional family member: $8,070 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $10,095 for Alaska; and $9,285 for Hawaii.

I am a dependent student

Yes (complete the next section)No (skip ahead to "Independent Student" section)
If you selected yes to the question above, the following section needs to be completed by your parents. Select the appropriate statement.

As the parent of the above student, I certify that the taxable income as reported on last years federal 1040 does qualify my student for the program based on the table above.As the parent of the above student, I certify that I did not file a federal 1040 last year. Our taxable income is such that my student still qualifies for the TRiO program based on income.My student does not qualify for the program based on income, but still may qualify based on other qualifications.In lieu of a handwritten signature, by typing my name below, I, as the parent, certify the income information to be true and accurate.
By signing my name below, I, as the parent, certify the income information to be true and accurate.
Signature of Parent/Guardian

Clear
I am an independent student

YesNo
If you selected yes to the above question, please select the appropriate statement based on the chart showing family size and taxable income.

As an independent student, I qualify for the TRiO program based on the income guidelines stated above.I certify that I did not file a federal 1040 last year. My taxable income is such that I still qualify for the TRiO program based on the above chart.I do not qualify for the program based on income, but still may qualify based on other qualifications.
If selected for TRiO, I agree to being contacted by text message.

YesNo
If selected for TRiO, I agree that pictures, which include me (taken at TRiO events) can be published in TRiO literature, correspondence, bulletin boards, and social media

YesNo
Do you care for a child?

YesNo
Do you care for an aging relative?

YesNo
Additional Questions/Comments
I certify that the information provided on this application is true, accurate, and completed to the best of my knowledge. I understand that this information is confidential and will be used for grant purposes. I hereby authorize Parkland College’s TRiO program to secure information pertinent to my participation in TRiO. This release covers the ability to access academic data and speak with interested parties, including past, present, and future professors regarding anything that might inhibit or enhance academic success. This includes, but is not limited to, access to financial aid information, standardized test scores, transcripts, grade reports, and any information concerning my academic progress and performance.

By signing my name below, I acknowledge that this to be my signature.
Signature of Student

Clear