Northwest State Community College-SSS-Application Form

TRIO - STUDENT SUPPORT SERVICES APPLICATION
Per the Family Educational Rights and Privacy Act (FERPA), information in this application is confidential – we will protect your sensitive personal data. Print Clearly. Incomplete applications may be returned to you or rejected.
- Full Name:*
  
  First NameMiddle NameLast Name
- Preferred Name:
- Address:*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone:*
  (999)999-9999
- NSCC ID#:*
  N00-
- Date of Birth:*
  
  MonthDayYear
  mm-dd-yyyy
- NSCC Email address:*
  example@example.com
- In accordance with federal regulations, a student must meet one of the following criteria to be eligible for program services:
- Are you a first generation college student (neither parent has a Bachelor's degree)
  
  YESNO
- Do you have a documented disability?
  
  YESNO
- If yes, have you met with Accessibility Services at NSCC?
  
  YESNO
- Do you have limited income?
  
  YESNO
- (Note: the U.S. Department of Education will not recognize other designations outside of those listed below.)
- Gender:*
  
  MaleFemaleNonbinary or other gender
- Marital Status:*
  
  SingleMarriedDivorcedWidowed
- Citizenship Status:*
  
  U.S. CitizenPermanent ResidentOther
- Race or Ethnicity (check all that apply):*
  
  Black or African AmericanHispanic or LatinoWhiteAsianNative Hawaiian or other Pacific IslanderAmerican Indian or Alaska Native
- Do you speak English as a Second Language (ESOL)?
  
  YesNo
- If yes, primary language spoken:
- Have you ever been enrolled in an ESOL program?
  
  YesNo
- Were you ever a member of any of the following Access Programs at another college?
  
  YesNo
- If yes, check with ones.
  
  Upward BoundEducational Talent SearchEOCOther
- Major:*
- Academic Advisor Name:
- High School GPA (if less than 3 years after graduation):
- What is your expected year of graduation from NSCC?*
- Are you*
  
  Full timePart time
- What is your current NSCC academic status?
  
  Good StandingSuspensionProbation
- If you and/or your family filed income taxes last year, what was your combined TAXABLE INCOME? Note: It is REQUIRED that you indicate TAXABLE income and not total income or adjusted gross income. Taxable income is reported on your 1040. (Please note your application will be incomplete without the REQUIED FIELDS marked with a *)
- Taxable Income*
  
  Less than $23,940Less than $32,460Less than $40,980Less than $49,500Less than $58,020Less than $66,540Less than $75,060Less than $83,580OtherOther
- Number of people living in your household including yourself*
- Are you designated as an Independent Student for financial aid here at NSCC?*
  
  YesNo
- Please check all that apply: (if not applicable please skip)
  
  At least 24 years oldOrphan/Ward of CourtA parentHomelessA VeteranAged out of foster care
- Have you completed a Bachelor's degree?*
  
  YESNO
- Has it been determined by a court in your state of legal residence that you are an emancipated minor or that you are in a legal guardianship?
  
  YESNO
- I certify that the information I provided about my family size and taxable income is true to the best of my knowledge. I also grant Northwest State Community College TRIO-Student Support Services permission to access my official records to complete my application. (Your application will not be complete without signatures and dates.)
  
  YesNo
- I give Student Support Services (SSS) permission to access my educational records, including financial aid information, for income verification and participation in the SSS program. I understand that all records are kept confidential in accordance with Northwest State Community College and Federal Privacy Laws.
  
  YesNo
- I certify that the above information is complete and accurate to the best of my knowledge.
  
  YesNo
- I give permission for release of my data (name, photos, data related to awards and achievements) for purpose of awards, recognition and advertising.
  
  YesNo
- Permission to take my picture for recognition and advertising purposes
  
  YesNo
- Please sign, date and return this form. If you are considered a dependent, as defined by Free Application for Federal Student Aid (FAFSA), you must have your parent/guardian sign and date this form.
- Printed student name:
  
  First NameLast Name
- Student Signature:
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Print parent/guardian name (if claimed as dependent):
  
  First NameLast Name
- Parent or Guardian Signature:
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Completed applications may be mailed, hand-delivered, faxed/scanned or emailed.
  
  Return to:
  
  TRIO-Student Support Services
  22-600 St. Rt. 34
  Archbold, OH 43502
  
  Email: triosss@northweststate.edu
  (Please indicate “SSS Application-Your Name” in the subject line)
  
  Phone: 419-267-1339
  Fax: 419-267-5657
- Note: Applying for this program is a commitment and we expect you to be an active participant while you are a student at Northwest State Community College.
  
  If you are admitted to NSCC TRIO Student Support Services, we will require the following commitment from you:
  - Meet with my Success Coach at least twice a semester.
  - Participate in tutoring sessions as needed
  - Participate in financial aid and career development workshops and events.
  - Set goals with my Success Coach that lead to my planned graduation.
  - Work with my Success Coach to assist with transfering to a four year college after graduation, if a bachelors degree is desired
- How did you learn about NSCC TRIO Student Support Services? Please select what applies:
  
  NSCC Staff/FacultyEmailMailing/FlyerNSCC WebsiteAnother TRIO StudentOther
- If NSCC Staff/Faculty, who?

TRIO - STUDENT SUPPORT SERVICES APPLICATION