Arapahoe Community College-SSS-Application Form

TRIO Student Support Services - Program Application

Please do your best to answer all sections of this application. Your responses are needed to determine eligibility for this federally funded program. Because of the personal nature of some of these questions, your responses will be held in the strictest confidence. Any questions, please contact TRIO SSS office at 303.797.5755.

ELIGIBILITY REQUIREMENTS

The TRIO Student Support Services program serves a limited number of students each year and applying for the program does not guarantee acceptance. Applications are evaluated based on the number of available slots, individual academic need, and federal eligibility.

To be eligible for this program you must meet the following:
- Accepted for enrollment at ACC
- Have a need for academic support to aid in successful completion of courses at ACC
- You must be:
  - A first-generation college student (neither parent or guardian has a 4-year degree) OR
  - Considered limited-income (according to the US Census Taxable Income Levels) OR
  - An individual with a documented disability registered with Disability Access Services at ACC
Student Name*

First NameMiddle Initial (optional)Last Name
Student ID Number*
Example S00012345
Cell Phone
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Please use your student email if you have one. Example example@student.cccs.edu

Self-assessment, Program Services, and Student Background
TRIO SSS uses this survey to best serve students. The information is kept strictly confidential. Honest answers help TRIO SSS best meet your needs, but feel free to withhold personal information if you are not comfortable disclosing. There are no right or wrong answers.

Self-Assessment: Please identify your current skill level in the following areas using the following scale.

	Skill is challenging	Comfortable with this skill	One of my best skills
Balancing school-work-life
Self-discipline/Focus
Perseverance/Determination
Self-confidence
Managing stress
Verbal communication skills
Math skills
Writing skills
Reading skills
Study skills
Technology use
Library Research skills
Note-taking techniques
Test-taking strategies
Time management

TRIO SSS Services: Please identify the most helpful services (check from three to five services only)

Selecting a majorCourse selectionStudy skills developmentPersonal counselingSelf-confidence buildingUnderstanding the college environmentCareer planningFinancial managementScholarship researchTransfer school preparationFinancial aid advisingAccess to social/cultural activitiesTutoringOther
Student Background
Will you be working while attending college?

YesNo
How many hours per week?
Is English your primary language?

YesNo
What is your primary language?
Do you feel comfortable with technology (email, computer, et cetera)?

YesNo
Are you a Veteran of the U.S. Armed Forces?

YesNo
Do you receive any scholarships?

YesNoWhich scholarships?
Are there any additional obstacles that impact your education (i.e. access to stable housing, access to resources to meet basic needs such as food, childcare et cetera)?

YesNo
Please explain

Short Answers
Please provide at least a three to five sentence response to each question below. TRIO SSS uses these responses to best serve students. The information is kept strictly confidential. Honest answers help TRIO SSS best meet your needs, but feel free to withhold personal information if you are not comfortable disclosing. There are no right or wrong answers.
1. Why did you choose to go to college, and why did you select ACC in particular?
2. What are your career and educational goals (be sure to describe your plan and timeline to finish your associate's degree and beyond)?
3. How do you plan to TRIO support services in your time at ACC? What role do you think TRIO will play in reaching your future goals?
4. What personal or academic challenges must you overcome in order to reach your educational goals?
TRUTH STATEMENT

By signing this application, I certify the information provided on this form is, to the best of my knowledge, accurate and true. By entering my full legal name below, I am creating an electronic signature as binding as my handwritten signature.
Name*

First NameMiddle Name (optional)Last Name