North Carolina Central University-DSSS-Application Form

TRIO STUDENT ACCE[SSS] PROGRAM APPLICATION
Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
mm-dd-yyyy
Academic Semester*

Fall 2021Spring 2022Summer 2022Fall 2022Spring 2023Summer 2023
NCCU Student ID Number (820 #)*
NCCU Email Address *
example@example.com
Birth Date*

MonthDayYear
mm-dd-yyyy
Social Security Number*
999-99-9999
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I identify as*

Native AmericanAsianWhite/CaucasianBlack/AfricanHispanic, LatinxHawaiian, Pacific Islander2+ EthnicitiesI prefer not to answerOther
Gender*

MaleFemaleNon-BinaryPrefer Not to SayOther
Phone Number*
(999)999-9999
Do you agree to receive text messages by NCCU SSS Faculty or Staff?*

I agreeI do not agree
Are you a US Citizen?*

YesNo
Are you a Permanent Resident?*

YesNo
What is your Dependency Status?*

Independent (You claim yourself on your tax return)Dependent (Someone else can claim you on their tax return)
What is your main source of income?*
Are you lawfully considered Homeless Youth or Foster Youth by the state you resided in before coming to NCCU? *You will need to provide documentation*

YesNo
Who did you reside with while growing up?*

Two legal parents, guardians or caregiversOne legal parent, guardian, or caregiverOther
Please provide the name(s) of the legal parent(s), guardian(s), or caregiver(s) that you resided with*
Did either of your legal parent(s), guardian(s), or caregiver(s) earn abachelors degree?*

YesNo
If you are claimed on a parent's/guardian's/caregiver's taxes: what is the taxable income they reported on their 2020 taxes? If you claim yourself: what is the taxable income you reported on your 2020 taxes?
You can find taxable income on: line 43 on the 1040, tax form, line 6 on the 1040EZ, or line 27 on the 1040A
If you are claimed on a parent's/guardian's/caregiver's taxes: what is the household size they reported on their 2020 taxes? If you claim yourself: what is the household size you reported on your 2020 taxes?

12345678910
Did you complete your 2021-2022 FAFSA?*

YesNo
Are you registered with NCCU's Student Accessibility Service (SAS) office?*

YesNo
Are you enrolled full-time this semester and/or the first semester you plan to enroll? Full time during Fall, Spring, & Summer C is 12 credits, Full Time during Summer A or B is 6 credits*

YesNo
Do you have an accommodation from the Student Accessibility Service office stating that you can be enrolled in less credits and still be considered full time?*

YesNo
Are you a transfer Student?*

YesNo
What are the previous college(s) you attended? What is your most current GPA?*
What is your NCCU Classification?*

FreshmanSophomoreJuniorSenior
When did you- or when will you- start at NCCU? (Examples: Fall 2016, Spring 2019, etc.)*
Which high school did you graduate from? What was your GPA upon graduation?*
What is your current NCCU GPA?*
Were you in a TRiO program at any of your previous institutions?*

YesNo
Please select the TRiO/First Generation Student Success Programs you are apart of/have been a part of:*

TRIO Student Support ServicesTRIO McNair Scholars ProgramAnnie Day Shepard Scholars/ Women's CenterAfrican-American Male Initiative/ Men's Achievement CenterCheatham-White ScholarsUniversity Honors ProgramTRIO Educational Opportunity CentersTRIO Upward Bound ProgramTRIO Educational Talent Search ProgramGEAR UPNONE OF THE ABOVE
How did you hear about NCCU TRIO SASP Program?*

Email/Website/FlyerTRIO SASP Faculty or StaffOther NCCU Faculty or StaffUniversity CollegeAcademic AdvisorA Friend or PeerOther
Which (Most Closely) Matches Your Intended Major?*

Business, Finance,MarketingBiology, Chemistry, Physics EducationPsychology, Sociology,CriminologyEngineering, Architecture, orConstructionAgriculture & Life Sciences,Sustainability, MarineScience, Meteorology,Geology, EnvironmentalSciences, ZoologyWomen & Gender Studies,Family Youth & CommunitySciencesHistory, Language,Anthropology, Religion MathematicsHealth Professions, PublicHealthComputers, Technology Journalism & MassCommunications, MarketingArts, Design
Please choose the resources and/or services you think you will need while you are at NCCU*

Scholarships/FundingAcademic Advising or Selecting CoursesAssistance in Completing Financial Aid FormsTutoringDiscussing graduate schoolFinancial & Economic LiteracyMentorshipGRE PreparationCareer Counseling
Please choose any of the following that apply to you*

Academic challenges in high schoolChallenges in humanities, writing, and social studies classesScore lower than 20 on ACTTest anxietyScore lower than 1000 on SATI have my GED or another high school equivalency that is not a diplomaAssistance with educational/career goalsLimited English proficiencyI would like to raise my gradesOut of higher education for 5 or more yearsChallenges in science, technology, engineering or math classes
Which documentation will you upload for TRIO Financial Verification? (check all that you will submit, you must submit at least one).*

Signed 2020 tax return formFAFSA Student Aid Report (SAR)Verification of family income from another governmental sourceA signed statement regarding income from independent student or parent
Upload your financial documentation here (must be signed by parent/guardian if dependent): You can get a copy of your Student Aid Report (SAR) by logging in to fafsa.gov using your FSA ID and selecting the "View or Print your Student Aid Report (SAR)" option near the middle of the "My FAFSA" page. Save it as a PDF file and upload it here.*

Cancelof
I hereby give permission for the North Carolina Central University Office of
Student Accessibility Services to take my picture as part of my participation in
one of its student success programs (TRIO Student Acce[SSS] Program). I
understand that this picture may be published and used in all types of public
relations related activities in which the program may be involved. I understand
that my picture may be published along with any related information about
myself that is appropriate to the activity.

By signing your full name in the following space, you are agreeing to
the following statement:
I agree that the information on my application is true and accurate, to the
best of my knowledge. I am submitting this application for consideration
into the NCCU TRIO Student Acce[SSS] Program. If selected for the
program, I agree to participate.
Signature*

Clear
Academic and Financial Release Statement: I hereby give permission for the North Carolina Central University, Student Support Services Program to obtain any and all of my academic records, including college and high school transcripts, test scores and records, teacher evaluations, financial aid information and supplemental academic information.

I understand that these records will only be used internally by the program and on an individual basis. I also understand that records compiled on a group basis may include any and all of these records. I also understand that the compiled information will be used to determine my eligibility for the program, program evaluations, performance reports, and any related uses.
Signature*

Clear
Infraction and Consequences statement: I have read, understood and agreed to the conditions for acceptance in the NCCU-SSS program. I understand that NCCU-Acce[SSS] staff will discuss my eligibility to continue in the program. I recognize that failure to meet the expectations or comply with the requirements outlined in this Student Participation Agreement equates to infringement and will affect my eligibility, and may lead to a limitation of services and program benefits, up to and including, dismissal from the Program.

I understand that if I am dismissed from the Program and would like to reenter within the academic year, I must have a conference with the Program Director to review my status. Otherwise, I must fully reapply to the program after one year.
Signature*

Clear