Redlands Community College-SSS-Application Form

Name*

First NameMiddle InitialLast Name

Student ID #

Sex*

MaleFemalePrefer not to answerOther

Birth Date*

mm-dd-yyyy

Social Security Number *

999-99-9999

Mailing Address

Street Address

CityState

Zip Code

Home Address

Street Address

CityState

Zip Code

Home Phone

(999)999-9999

Cell Phone *

(999)999-9999

Home Email*

example@example.com

School Email

example@example.com

X the appropriate category*

Are you a U.S. Citizen?*

YesNo

Are you applying for Financial Aid (FAFSA)?*

YesNo

If yes, will you be eligible for Pell Grant?*

YesNo

If yes, were you required to put your parent(s) information on the FAFSA?*

YesNo

If you answered yes, how many people are in your parent or parents' household (including you)?

Please, submit copies of your parent's most recent income taxes

If you answered no, how many people are in your household (including you)?

Please, submit copies of your most recent income taxes

Did EITHER of your parents graduate from a 4-year college/university*

YesNo

If YES, from what school?

Have you participated in (check ALL that apply)

Do you have any professionally diagnoses physical or learning accommodation needs?*

YesNo

If yes, which one(s)?

Are you currently in Foster Care*

YesNo

Are you currently homeless*

YesNo

PARTICIPANT CERTIFICATION AND CONTRACT AGREEMENT

I CERTIFY that the information I HAVE provided in applying to Project AIMS is tue and correct to the best of my knowledge. I GIVE Project AIMS my permission to recieve copies of my educational records and other matericals necessary for participation in the Project in accordance with the Provacy Act of 1974, all my records will be kept in confidence. I also give permission to have any photos taken used for Project AIMS Web site, recruiting materials, and other project related activites. I ACKNOWLEDGE that I HAVE discussed the ACADEMIC PLAN OF ACTION with Project AIMS Staff and I REALIZE that it is subject to revision. I HAVE RECEIVED information on financial aid and I WILL PARTICIPATE in recommended Project services and activities that will support increased success in college and improve my transferbility. I AGREE to make regular contact with a Project AIMS Staff Person.

Participant Signature

Date

mm-dd-yyyy