University Of Illinois-Chicago-SSS-Application Form

University Of Illinois-Chicago-SSS-Application Form
The following information is needed to assess your eligibility for TRIO Student Support Services (SSS) at the University of Illinois Chicago. This information will be treated confidentially.

FIRST GENERATION VERIFICATION
Does your mother/adopted mother have a four-year degree?*

YesNo
Does your father/adopted father have a four-year degree?*

YesNo

DISABILITY VERIFICATION
Do you have a documented disability?*

YesNo

Authorization to Release School Records Information
Name*

First NameMiddle InitialLast Name
Date of birth*

MonthDayYear
mm-dd-yyyy
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
UIN*
I hereby authorize the release of information regarding my enrollment status, financial aid award letter, school transcript, copies of achievement/standardized tests taken, grades and any other pertinent information to TRIO Student Support Services at the University of Illinois Chicago.

I understand TRIO Student Support Services is required to obtain current and updated information regarding my enrollment status.

I understand that this information will be kept confidential and be used to maintain fallow-up data and for general reports to the United States Department of Education.
Student Signature*

Clear
Today’s Date*

MonthDayYear
mm-dd-yyyy

TRIO Student Support Services (SSS) Agreement
Name*

First NameLast Name
I, {name59}, understand the requirements stated below and agree that while involved in TRIO, I will adhere to the requirements. (Please initial each item to show that you have read and understand it.)
1. Each academic semester, I will complete the following SSS academic components:*
Please initial
1.1. Meet with each of my instructors at the midpoint of the semester to complete and sign the Course Progress Forms. Once the forms are completed, I will return the forms to my SSS Advisor by the designated deadline. Deadlines will be shared on a semester basis. If any of my grades fall below a “C” I will have to meet with my SSS Advisor to discuss an academic recovery plan.

1.2. Meet with an academic advisor in my intended major to discuss my degree progress and complete and sign the TRIO Academic Advising Form. I also will complete the Degree Completion Plan Form with my academic advisor. This form only must be completed one time unless you change your major. I will return the forms to my SSS Advisor by the designated deadline. Deadlines will be shared on a semester basis.

1.3. Attend a minimum of two follow up meetings with my SSS Advisor.
2. Each academic semester, I will participate in a minimum of two TRIO SSS events. *
Please initial
My first follow up meeting is on this date:*

MonthDayYear
mm-dd-yyyy
My first follow up meeting is on this time:*
3. Each academic year, I will attend the following TRIO Student Support Services Events:

• TRIO Weeks of Welcome
• Advising Week- Twice during fall & spring semester (4 total)
• TRIO Spring Gathering:
• TRIO Scholars Recognition Ceremony
I will attend the TRIO Student Support Services Events.*
Please initial
4. I will read my UIC email regularly and respond to emails regarding TRIO SSS in a timely manner.*
Please initial
5. I understand that as a TRIO Scholar, I am expected to remain active in the program throughout my time at UIC.*
Please initial
Student Signature*

Clear
Today’s Date*

MonthDayYear
mm-dd-yyyy

SIGNATURE
I verify that all the information contained in this application is true to the best of my knowledge.
Student Signature*

Clear
Today’s Date*

MonthDayYear
mm-dd-yyyy
In 3 or 4 sentences, please identify at least one goal and how TRIO can assist with your goal.*