Joliet Junior College-SSS-2022 Intake Form

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Center for Multicultural Access & Success

All information submitted will be secured in compliance with the Family Educational Rights and Privacy Act.
Name*

First NameMiddle InitialLast Name
JJC Student ID #
Telephone Number
(999)999-9999
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Educational Information
What are your educational goals? Check all that apply:

Earn an A.A., A.A.S., or A.S. DegreeTransfer to a 4-year college/universityCertificate or DiplomaComplete courses but not obtain a degreeUndecided
What is your current or intended major or area of study?
How many credits do you plan to enroll in each semester?
credits per semester
Have you participated in a college access program such as Upward Bound or Educational Talent Search? If so, which program? :
Which High School did you attend?
Year of Graduation

Personal Statement Questions
Please carefully read and answer the following questions using complete sentences.
1. What are your educational and career goals?
2. What other demands do you have on your time?
3. What academic challenges are you facing?
4. How can CMAS & TRIO SSS support you to achieve your goals?

Certification/Release of Information
I certify that the information I have provided is true and correct to the best of my knowledge. I authorize program staff to receive my transcripts, grades, financial aid data, documentation of a disability, recommendations and evaluations in order to determine eligibility and fulfill the requirements of the TRIO Student Support Services Program at Joliet Junior College.
I acknowledge that I have completed all necessary steps in the TRIO SSS application process below:*

I understand that I must complete an application interview with a CMAS advisorI understand that a CMAS advisor will follow up with me regarding my admission to the program
Further, if admitted to the TRIO SSS program, I agree to the following participation requirements:*

Attend 1 CMAS TRIO sponsored event and meet with my assigned advisor twice throughout the academic semesterContact my CMAS advisor before withdrawing from a course to explore options such as tutoring, workshops, and meeting with my instructor to discuss course progress
Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy

Photo Release
Periodically, the Center for Multicultural Access & Success Department will use pictures of student participants in printed materials and/or the program’s web page. I understand that such pictures will be used for the purpose of recognizing student accomplishments, documenting program events, and/or publicizing the program. I authorize Joliet Junior College and TRIO Student Support Services to use and reproduce photography(s) of me for these purposes. I further give permission for TRIO Student Support Service to include my name in such publications.*

Yes, Joliet Junior College CMAS may take my photo and I give my permission for the duration that I am a participant in CMAS. In giving this approval, I relinquish all rights to any advertising and/or marketing materials that may be produced containing my photograph.No, Joliet Junior College CMAS may not use my photo. By checking no, I understand that my photo will not be used in advertising and/or marketing materials.
Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy

Center for Multicultural Access & Success