Lone Star College-Kingwood-SSS-Application Form

Lone Star College
LSC ID Number *
Date of Birth*

MonthDayYear
mm-dd-yyyy
Name*

First NameMiddle Initial Last Name
Gender*

MaleFemale
Ethnicity-Hispanic*

YesNo
Race (Choose all that apply)*

American-Indian/Alaskan NativeBlack/African AmericanNative Hawaiian/Other Pacific IslanderAsianWhite
Academic Need (Check all that apply)

Low grades in high schoolLow test scoresFailing grades, out of school for 5+ yearsLimited English proficiencyImprove educational or career goalsRequesting additional academic preparationImprove grades
First Enrollment Date at LSC*
Enrollment Status

Full-time: (at least 24 credit hours per year)3/4 time (at least 18 credit hours per year)1/2 time (at least 12 credit hours per year)Less than 1/2 time (fewer than 12 credit hours per year)
GPA*
If you are do not have a LSC GPA yet, or you are unsure, please enter 0
Services interested in*

Leadership and Student SuccessTutoringCultural ExperiencesFinancial LiteracyCollege transfer informationCollege Excursions
Home Campus

KingwoodMontgomeryTomballNorth HarrisCy-FairUniversity ParkHouston NorthLSC-Online
Are you currently participating in another TRIO program?*

YesNo
The College Advancement Program at LSC-Kingdom is funded by the U.S. Department of Education's TRIO Student Support Services grant. Eligibility requirements include:
U.S. Citizenship or Permanent Resident, a demonstrated academic need, a Lone Star College student and satisfy one or more of the following: (Choose all that apply)*

Documented DisabilityLimited Income (Based upon federal guidelines and eligible to receive a Pell Grant)First-Generation (Neither parent has earned a Bachelor's degree)
Citizenship (choose one)*

U.S. CitizenPermanent ResidentOther
Financial Aid Recipient*

YesNo
Are you currently enrolled at LSC?*

YesNo
Were you formerly

In foster careA ward of the courtNeither
Education: Select all that apply*

GEDDevelopmental ClassesCompleted at least one semester of collegeHigh School diplomaDisplace WorkerAttended another collegeVeteran status
Educational Goals (Select all that apply)*

Associates Degree (AA, AS, AAS)Transfer OnlyCertificate ProgramGraduate and transfer to a college/university
Major*
Career Goals *
Do you work?*

YesNo
What other competing priorities do you currently have?*
Please share why you are interested in the TRIO College Advancement Program? What challenges are you currently facing and how can this program assist you in reaching your goals?*
Phone Number *
(999)999-9999
Alternative Phone Number
(999)999-9999
LSC Email*
example@example.com
Confirm Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student Certification and Release:

I,____, have read and personally completed the application and I confirm that the information is ture and correct. I understand that completion of this form does not gaurantee admission in The College Advancment Program (TRIO Student Support Services). As a prospective TRIO student, I authorize permission to utilize the National School Cleaninghouse to record my academic performance and also agree to the following terms: I will submit all necessary and supporting documentation including IRS tac form documentation, FAFSA Student Aid Reprort (SAR), and the verification from the Office of Disability Services (if you receive from them). The Department of Education requires that we authenticate and obtain a copy of the requested items for all prospective participants. Your information is confidential and secure. It will only be accessed by the program staff or the Department of Education upon request.
Student Verification and Release*

I agree
Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Documentation Verification is required: (please upload documents. If you are not able to upload, please use the comment box to explain).
IRS: Last Tax Returns

Cancelof
FAFSA (SAR)

Cancelof
Documented Disability

Cancelof
Government issued ID (Drivers License, State ID or Passport)*

Cancelof
Comment