Baltimore City Community College-SSS-Application Form

TRIO Student Support Services Program

APPLICATION FORM

Please answer all questions completely. Submit all required documentation with this application. All incomplete applications will not be processed.

Please upload your Student Inquiry from the BCCC Panther Portal into your program application.

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Social Security Number*
999-99-9999
Banner ID Number
Name*

First NameMILast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (Primary)*
(999)999-9999
Phone (Secondary)
(999)999-9999
Email Address (BCCC)*
example@example.com
Alternate Email Address
example@example.com
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemale
Residency Status*

U.S. CitizenPermanent Resident (Please include Alien # below)Other
Alien #
Race/Ethnicity (check all that apply)*

Hispanic/LatinoBlack/African AmericanAsianWhiteAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific Islander
Is English your first language?

YesNo
If no, what is your native language?
Have you ever participated in any of the following TRIO Programs?

YesNo
If yes, check all that apply.

Educational Talent SearchUpward BoundStudent Support ServicesEqual Opportunity Center
Do you have any disabilities?*

YesNo
If yes, are you registered with BCCC’s Disability Support Services Center?

YesNo
Did you regularly live with your natural or adoptive parents or receive support from a natural or adoptive parent before you turned 18?*

YesNo

What is the highest level of education achieved by your natural or adoptive parent(s) BEFORE YOUR 18TH BIRTHDAY? (If parents are divorced, reply only in regards to the parent you grew up with.) *

Rows	Grade School	High School	2 Year Degree	4 Year Degree	Beyond 4 Year College Degree
Mother
Father

Have you applied for Financial Aid?*

YesNo
Have you received an award?*

YesNoPending
If yes, what type?

Pell GrantSEOGWork-StudyMD Educ. Assistance GrantBCCC FoundationScholarshipOther
How did you learn about the TRIO SSS Program?

OrientationStudent/FriendTRIO SSS ParticipantFacultyStaffBCCC WebsiteFlyer/PosterBCCC PublicationAdmissions MailingSocial-mediaEmailOther
Name if referred by a student, friend, faculty, or staff member
Emergency Contact
Name*

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

Intended major*
Date of first semester at BCCC*
Month/Year
Date of first semester at BCCC*

MonthDayYear
mm/dd/yyyy
Class Standing*

First SemesterTransfer StudentFreshman (0-29 credit hrs.)Sophomore (30+ credit hrs.)
Did/ Do you have to take developmental courses?*

YesNo
Check ALL that you have already PASSED

Mat 86Mat 92Reng 91Reng 92
Please indicate the academic difficulties you have encountered in college while pursuing your educational/career goals. Check all that apply*

Poor Reading/Writing SkillsPoor Math SkillsPoor Study SkillsTime managementTest Taking SkillsLow GradesFailing GradesOther
High School Attended
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Graduation Date

MonthDayYear
mm-dd-yyyy
GPA
If you did not receive a high school diploma, have you earned a GED?

YesNo

Other Colleges/Universities/Training Facilities attended

Rows	College Name/Location	Dates Attended
1
2

Do you have an Associate’s Degree?*

YesNo
Do you have a Bachelor's Degree?*

YesNo
Do you have a certificate?*

YesNo
Have you been out of school for 5 or more years? *

YesNo
If yes, when was the last time you took classes at any college including BCCC?

MonthDayYear
MM-DD-YYYY
Are you clear about your educational and/or career goals?*

YesNoNot Sure
What services are you interested in receiving? (Check all that apply.)*

TutoringCollege Success SkillsCareer AdvisingPersonal CounselingFinancial Aid PlanningCultural ActivitiesAcademic AdvisingTransfer ServicesFinancial LiteracyWriting SkillsOther
In which of the following BCCC programs/services do you participate? (Check all that apply.)

Granville T. WoodsMayor’s Scholars ProgramPanther Success ProgramOther
Do you plan to transfer to a 4-year College/University?*

YesNoUndecided

Colleges/Universities of Interest

Rows	College/University Name
1
2
3

In order to determine your income eligibility for the TRIO SSS Program, you must provide us with the information requested in Section (A) or provide one of the documents listed in Section (B).
Section A:
Marital Status*

SingleMarriedSeparatedDivorced
Are you an orphan or ward of the court?

YesNo
Are you a veteran of the Armed Forces of the United States?

YesNo
Are you at least 24 years old? *

YesNo
How many legal dependents do you have?*

01234567Other
If you answered no to all of the questions above, please have your parent or legal guardian complete the information below and sign.
Please check the range that indicates your family’s TAXABLE INCOME and not total income or adjusted gross income*

$0 to $23,475$23,476 to $31,725$31,726 to $39,975$39,976 to $48,225$48,226 to $56,475$56,476 to $64,725$64,726 to $72,975$72,976 to $81,225$81,226 and over
If you are unsure of your taxable income, please upload your most recent tax return for review.

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How many legal dependents (incl. yourself) are supported by the income reported above?*

If you (or your family) receive(s) assistance from any of the following, indicate the MONTHLY amount next to the ones you receive.

Rows	$ Amount
TCA/AFDC/ACD
Vocational Rehabilitation
Social Security
Veteran Benefits
Retirement Benefits
Other State/Federal Assistance (specify)

Section B:

Provide one of the following: (1) proof of your (or your parent’s/legal guardian’s) income from a government agency/source, or (2) a signed financial aid application, or (3) a signed income tax return from the United States or Puerto Rico (4) a signed statement from the individual or individual’s parent or guardians regarding family income.
Document Upload

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In applying for a federally funded program, you should know that anyone making a false statement or misrepresentation in establishing eligibility is subject to a fine or imprisonment or both under provisions of the U.S. criminal code. By my signature, I certify that the information provided in this application is true and correct to the best of my knowledge. Additionally, I authorize access to all my school records, from BCCC and any other college/university, to the TRIO Student Support Services Program for program purposes. Furthermore, I understand that the information from these records will be kept confidential. Upon acceptance to the program, I agree to meet with my advisor regularly, attend program activities and see a tutor regularly if enrolled in developmental courses, on Academic Warning, Probation, Dismissal, or repeating courses.
Applicant's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Legal Guardian's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Thank you for your interest in the TRIO SSS Program. It is our privilege to serve you.
Sincerely,
Dr. Leslie Jackson
Project Director, TRIO Student Support Services Program
Baltimore City Community College