Florida Gateway College-SSS-Interest Survey

TRiO Student Support Services (SSS)
Interest Survey

Please complete the interest survey below. A TRIO SSS staff member will contact you with more information about the program.

Name*

First NameLast Name

Email*

example@example.com

FGC Student ID*

Citizenship*

U.S. CitizenPermanent Resident AlienOther

Cell Phone Number*

(999)999-9999

Did your MOTHER graduate from college with a 4-year degree? *

YesNo

Did your FATHER graduate from college with a 4-year degree?*

YesNo

Have you completed your FAFSA?

YesNo

If yes, are you receiving PELL Grant

YesNo

What degree are you seeking?

Associate in ArtsAssociate in ScienceBachelor

Major

I am interested in learning more about TRiO SSS. Please contact me with more information about the program. I understand that completing this form does not guarantee me placement into TRiO SSS.

Student Signature

Date

mm-dd-yyyy

* Disclosure of information collected in these questions is not mandatory; however it is requested to aid the State of Florida in its commitment to Equal Educational and Employment Opportunity and to meet federal reporting requirements. It is not used discriminatively for admission purposes. Refusal to answer the information will not result in the adverse treatment of any applicant.

FGC will adhere to all applicable federal, state, and local laws, regulations, and guidelines with respect to providing reasonable accommodations as required to afford equal educational opportunity. Students may obtain further assistance and information by calling the Coordinator of Accessibility Services, at 386.754.4215. The Accessibility Services Office is located in Building 007, 149 SE College Place, Lake City, Florida 32025.
Florida Gateway College does not discriminate in education or employment related decisions on the basis of race, color, ethnicity, national origin, gender, religion, disability, age, marital status, genetic information, sexual orientation, pregnancy, or any other legally protected status in accordance with the law. The equity officer is Cassie Buckles, Executive Director of Human Resources & Equity Officer, Building 001, Room 116, 149 SE College Place, Lake City, FL 32025, and may be reached at cassandra.buckles@fgc.edu or (386) 754-4313.