Riverside Community College-Norco College-SSS-Application Form

Name

First NameLast Name

Student ID

The Student Support Services Programs are federally funded, therefore, we must document your family’s income for eligibility determination purposes only.

	Yes	No
As of today, are you, the student, married?
Are both of the student’s parents deceased, or are you (or were you until age 18) a ward/dependant of the court?
Do you, the student, have dependants who live with you and who receive more than half of their support from you?
Are you, the student, a veteran of the U.S. Armed Forces?
At any time since you turned age 13, were both your parents deceased, were you in foster care, a dependent or ward of the court?
As determined by a court in your state of legal residence, are you or were you an emancipated minor?
As determined by a court in your state of legal residence, are you or were you in legal guardianship?

HOUSEHOLD INCOME and SIZE

I answered YES to AT LEAST ONE of the statements, above. Complete the INDEPENDENT STUDENT section in the table below.

OR

I answered NO to ALL of the statements above. Complete the DEPENDENT STUDENT section in the table below, with your parent or guardian.

Provide the total number of persons in your household, including yourself

Select ONE and complete the required information

Yes, filed a federal income tax return last yearNo, I DID NOT FILE a federal income tax return last year.No, I did not have a taxable income last year

Provide your TAXABLE INCOME amount. Taxable income can be found on line 15 of the 2022 1040 form.

Provide your TAXABLE INCOME last year

Provide the total number of persons in your PARENTS/GUARDIANS household, including yourself

Select ONE and complete the required information

Yes, my PARENTS OR GUARDIANS filed a federal income tax return last yearNo, my PARENTS OR GUARDIANS DID NOT FILE a federal income tax return last year.No, my PARENTS OR GUARDIANS did not have taxable income last year

Provide their TAXABLE INCOME amount. Taxable income can be found on line 15 of the 2022 1040 form

Provide THEIR TAXABLE INCOME last year

1. Have you, the student or the parent, completed your IRS income tax return or another tax return listed in question 2?

Yes, the studentYes, the parentNo

Status of filer when filing

SingleMarried/Joint FilingHead of Household

2. What income tax return did you file or will you file?

IRS 1040IRS 1040A or 1040EZA foreign tax returnA tax return with Puerto Rico, another U.S. Territory, or Freely Associated State

Sources of income and their annual amounts

	Father/Stepfather	Mother/Stepmother	Independent Student
Employment (work)
Unemployment
Disability
Social Security Benefits
Public Assistance (i.e. TANF, Cal Works)
Child Support
Veteran's Support
Other

Year of sources of income

Father/Stepfather Job Title

Mother/Stepmother Job Title

Independent Student

3. TOTAL Family Yearly Income

Please use line 15 "Taxable Income" on the 2020 Tax return to identify your families yearly income.

4. TOTAL Number of Family Members, including student

I certify that the above information and income data is accurate to the best of my knowledge. I further understand that my records will be kept confidential in the
Student Support Services office and will be used for statistical information only.

Name *If you are a dependent student, your parent and/or guardian is required to submit their first and last name to certify the above financial information is accurate.

First NameLast Name

Signature *Note: Parent signature is required for all dependent students to certify the above financial information is accurate.

Date

mm-dd-yyyy

Field trips or excursions are for the purpose of education, cultural, and social enrichment. Norco College, the Riverside Community College District, the Board of Trustees, and College Employees or agents and the sureties shall not be held responsible under any circumstances whatsoever by the undersigned, his state, or heirs for any injury. Damage, or loss to the person which the undersigned uncured while attending the off-campus functions.

State of California Educational Code #72640 states: All persons making a field trip or excursion shall be deemed to have waived all claims against the district, or the State of California for injury, accident, illness, or death occurring during or by any reason of the field trip or excursion.

It is imperative that all participants observe the regulations set forth by our colleges and California Educational Code.

Riverside Community College District and the California State Education Code prohibit the consumption of alcoholic beverages during a college function regardless if you are 21 years old or over.
The use of an illegal substance is a violation of state and district regulations.
Destruction of any property is a violation of state law and district regulations. Any cost associated with such destruction is the responsibility of those involved.
Students are expected to attend all agenda events unless they have a valid excuse, which must be pre-approved by the advisor, coach or instructor.
After scheduled events, as outlined by the written agenda, are completed, the student will not be under the immediate and/or direct supervision of an employee of such district or board.
Any violation of the rules may result in exclusion from the future field trips, excursions and in severe cases; it may result in suspension or expulsion from the college.

Your signature on this document indicated that you have read the document, understand its expectation and liability limitations that you are of legal age to sign the waiver, and do so voluntarily.

Student Name

First NameLast Name

Student Signature

Date

mm-dd-yyyy

Participant's Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

RCCD Student ID#

Home Phone #

(999)999-9999

Cell Phone #

(999)999-9999

Date of Birth

mm-dd-yyyy

1st Emergency Contact

First NameLast Name

Relationship

Phone #

(999)999-9999

2nd Emergency Contact

First NameLast Name

Relationship

Phone #

(999)999-9999

Medical Insurance Information

Carrier

Hospital

Policy #

Group #

List known allergies

List any prescription medication

List any medical condition requiring special needs

In the event of any medical emergency, I grant to the college or any of its representatives the full authority to take action deemed necessary to protect my health and safety at my expense, including but not limited to placing the Participant under the care of a doctor or in a hospital at any place for medical examination and/or treatment, or returning the Participant to their home city at his or her expense if such return is deemed necessary after consultation with medical authorities.

Initial one of the following statements:

	Initials
I am 18 years of age or older and am the Participant
I am the parent or legal guardian of the Participant who is under 18 years of age to whom the above statements apply and for whose benefit I am executing this agreement.

Signature

Date

mm-dd-yyyy

Introduce yourself
Include information about your school and community
Describe your reasons for wanting to attend college
Describe your plans for the future
Describe why you want to be part of the SSS program

Type here