Central Lakes College-SSS-Application Form

TRIO Student Support Services Application

Central Lakes College
TRIO Student Support Services Application

Central Lakes College

501 West College Drive, Brainerd, Minnesota 56401

triosss@clcmn.edu/trio-sss/

All services are FREE to program participants thanks to a grant from the U.S. Department of Education and in-kind support from Central Lakes College. All participants 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*

MonthDayYear
mm-dd-yyyy
How did you find out about TRIO SSS?*
Cell Phone:*
(999)999-9999
Texting?*

YesNo
Date of Birth:*

MonthDayYear
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/AS/AASBachelor's Degree
High School Diploma Date:*

MonthDayYear
mm-dd-yyyy
GED Date:*

MonthDayYear
mm-dd-yyyy
AA or Bachelor's Degree Date:*

MonthDayYear
mm-dd-yyyy
Have either of the parents who raised you completed 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? Includes physical and/or learning disabilities as well as mental illnesses - Anxiety, depression, PTSD, ADHD, etc.

YesNo
If so, what is the documented disability
Where is it documented?
Please check which areas of assistance you would utilize?*

Academic Advising/Degree PlanningTransfer AdvisingFinancial Aid AdvisingChoosing a Major or Career DirectionBudgeting for College/ScholarshipsComputer Lab & Printing ServicesStudy Strategies/ Tutoring
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 institutionGraduate with a degree and may consider 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 transfer 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 government. 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, including the college Financial Aid office for eligibility and award information.
Student Signature*

Clear
Date*

MonthDayYear
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.

TRIO Student Support Services Application