Central Lakes College-SSS-Application Form

TRIO Student Support Services Application

Central Lakes College

501 West College Drive, Brainerd, Minnesota 56401

All services are FREE to program particiants thanks to a grant from the U.S. Department of Education and in-kind support from Central Lakes College. All particiants meet federal program eligibility guidelines.

Name:*

First NameLast Name

Email:*

example@example.com

Current Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Application*

mm-dd-yyyy

How did you find out about TRIO SSS?*

Cell Phone:*

(999)999-9999

Texting?*

YesNo

Date of Birth:*

mm-dd-yyyy

Citizenship:*

United StatesPermanent ResidentOther

Gender:*

Are you Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture, regardless of race)?*

YesNo

Racial background (Select all that apply):*

American Indian or Alaskan Native: A person having origins in any of the original place of North or South America (Including Central America) who maintains culture identification through tribal affiliation or community attachment.Asian: A person having origins in any of the original peoples of the Far East, South East Asia, or the Indian sub continent.Black or African American: A person having origins in any of the black racial groups of Africa.Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples in Hawaii, Guam, Samoa, or other Pacific Islands.White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.Prefers not to answer

Are you a Veteran?*

YesNo

Is English your first language?*

YesNo

Have you earned your:*

High School DiplomaGEDAA or Bachelor's Degree

High School Diploma Date:*

mm-dd-yyyy

GED Date:*

mm-dd-yyyy

AA or Bachelor's Degree Date:*

mm-dd-yyyy

Have either of your natural or adoptive parents completed or earned a 4-year college degree?*

UnknownYesNo

Have you participated in a TRIO program such as: Talent Search, Upward Bound or Student Support Services?*

YesNo

If yes, where?

One of our possible federal eligibility criteria is having a documented disability such as ADHD/ ADD, anxiety, depression, learning disabilities, physical disabilities, etc. Do you have a documented disability? If so, where is it documented? (school, doctor, therapists, etc.)

Do you have a documented disability?

YesNo

If so, what is the documented disability

Where is it documented?

Please check which areas of assistance you would utilize?*

Academic and Transfer Plans

What is your academic major or interest?*

What is your career plan or Interest?*

Have you taken any college courses?*

YesNo

If yes, where?

Did you have any grades in high school or college below a C?

YesNoUnsure

What is your academic goal at our Central Lakes College:*

Graduate with a degree and transfer to a 4-year institutionTake courses here and then transferGraduate with a degree and go directly into my career field. I am not considering transferring to a 4-year institution.

Release of Information

I certify that the information I have provided on this application is, to the best of my knowledge, complete and correct. Furthermore, I understand that by applying to the Student Support Services Program, I authorize Student Support Service staff to obtain records or data pertinent to my participation from other sources such as: National Student Clearing House, and to release information, as required by law of the terms of the Student Support Services grant, to the grant-funding agency of the United States governement. The Student Support Services Program staff has my permission to communicate verbally or otherwise with staff, faculty, and/or off-campus professionals on my behalf.

Student Signature*

Date*

mm-dd-yyyy

An affirmative action, equal opportunity employer and educator. If you need disability related accommodations to make these events accessible, please contact Accessibility Services, accessibilityservices@clcmn.edu or 218-855-8175. Consumers with hearing or speech disabilities may contact us via their preferred Telecommunications Relay Service.