Marian University-SSS-Application Form

TRIO-Student Support Services
Participant Application

Below are three student sections and one parent/guardian section that must be completed. At any time you may choose “SAVE” to save the form and continue it later. (You may also use “SAVE” to forward to your parent/guardian to complete their portion of the form. They can use “SAVE” to send it back.) After you hit “SUBMIT,” you can no longer make changes to the application.

Student Information
Name*

First NameMILast Name
Marian Email*
example@example.com
Home/Permanent Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
Preferred Name/Nickname
Date of Birth*

MonthDayYear
mm-dd-yyyy
U.S. Citizen*

YesNo
If no, Immigration Status
Race (check all that apply)*

American Indian or Alaskan NativeAsian AmericanBlack or African AmericanHispanic/LatinoNative Hawaiian or Other Pacific IslanderWhite
Gender*

MaleFemale
Gender Identity*
*As a federal program, we are required to report data (including sex) to the U.S. Dept. of Education. Collecting gender identity is not required, but is important to ensure support of all students.
Preferred Pronouns

Parents' Education*

	Yes	No
Did your mother complete a four-year college Bachelor’s degree?
Did your father complete a four-year college Bachelor’s degree?

Student Disability Status*

	Yes	No
Do you have a documented physical, psychological, or learning disability? IF yes, please provide documentation to the Student Accessibility Resources Office: accessibility@marianuniversity.edu

Homeless/Foster Youth*

	Yes	No
Have you been a foster child or have you aged out of the foster care system?
Have you previously been homeless?

Prior TRIO Participant*

	Yes	No
Have you previously participated in a TRIO or similar program?

Please read and initial each statement.*

	Initials
I agree to be an active participant in the TRIO-SSS program through graduation and follow the 3-2-1+ model for student success each semester. I will: (a) Meet with three (3) TRIO-SSS staff for individualized Academic, Career, and Financial coaching PLUS the First-year Success Coordinator; (b) Attend a minimum of two (2) TRIO-recommended educational workshops; (c) Participate in a minimum of one (1) social/cultural event each semester
If I am identified as needing academic assistance by professors or TRIO staff, I agree to meet regularly with the TRIO-SSS Academic Success Coordinator.
I will maintain regular communication with the TRIO-SSS program staff by stopping in the office regularly, reading newsletters, responding to emails and other requests.

Failure to do the above may result in dismissal from the program. Additionally:*

	Initials
I will be responsible for TRIO-SSS resources while they are in my care. Although all TRIO resources and events are FREE, a fee may be applied to my student account for damage or replacement. Additionally, a fee may also be collected for last-minute cancelation after committing to attend an event.
I understand that by participating in the TRIO-SSS program, I am giving permission to use my name and image in Marian University publications, including but not limited to TRIO-SSS social media, website and printed materials, unless I send written notification requesting to opt out of media and publications.
I authorize school officials (as stated in the Marian bulletin per FERPA regulations) to release information to TRIO-SSS to assist in providing services including but not limited to: Admission’s and Registrar’s Offices concerning my academic records, Advisors and faculty members to support my academic and career success, Center for Academic Support & Excellence/Student Accessibility Resources concerning documentation/accommodations, and Financial Aid and Business Offices concerning my financial statements

Signature of Student*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Were you referred to our program by a current participant? If so, who referred you?

Parent/Guardian Section (This section must be completed and signed by a parent/guardian!)
For dependent students (usually under 24 years old), this section must be completed and signed by a parent/guardian. Independent students (students who are married, have children, or are 24 years of age or older) can complete this section on their own. List taxable income (as reported on line 15 of IRS Form 1040) to help us determine income eligibility. Please verify that the amount you enter matches the same amount listed on your tax form.
Total Family Size (include all people who reside in the home, including yourself): *
This is the household’s number of family members including self, spouse and/or dependents
Taxable Income (as reported on line 15 of IRS Form 1040):*
Note: Taxable income is generally much lower and reporting incorrectly could greatly affect eligibility. Use number from Line 15 of Form 1040 of 2023 tax form
Signature Head of Household*

Clear
* Signature of student only if “independent” according to federal financial aid standards
Date*

MonthDayYear
mm-dd-yyyy
Return as soon as possible to be considered
for TRIO-Student Support Services program.

Contact us with any questions:
trio.sssoffice@marianuniversity.edu
(920) 923-8632