Caldwell Community College & Technical Inst-SSS-Application Form

TRIO/Student Support Services Program Application
- Name:
  
  First NameMiddle NameLast Name
- Goes by
- Student ID #
- Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Campus
- CCCTI Email Address
  example@example.com
- Alternate Email Address
  example@example.com
- Cell Phone
  (999)999-9999
- Home Phone
  (999)999-9999
- Preferred Method of Contact (Check ALL that apply)
- Emergency Contact: Name
  
  First NameLast Name
- Emergency Contact: Phone
  (999)999-9999
- Emergency Contact: Relationship
- Race/Ethnicity (Check all that apply)
- H.S. Graduate?
- Year
- GED?
- Year
- College credits at another institution?
- Enrollment Status at CCCTI: Are you currently enrolled or accepted at CCCTI for enrollment in the next academic term?
- Curriculum
- Before you turned 18, did either parent or guardian with whom you reside/resided have a bachelor’s degree?
- Mother/Female Guardian:
- Father/Male Guardian:
- Please complete only 1 of the 3 sections below. Check the appropriate box to indicate your chosen method of income verification.
  
  If you are an independent student as defined by the Financial Aid office, please use your own income information.
  
  If you are a dependent student as defined by the Financial Aid office, please use your parent/guardian’s income information.
- Option 1: Income Tax Return Included
  
  I am including my/my parent or guardian’s income tax return for last year with this application.
- Tax Return
  
  Cancelof
- Option 2: Financial Aid Application Included
  
  I am including my financial aid application with this application
- Financial Aid Application
  
  Cancelof
- Option 3: Statement including Family Taxable Income and Family Size
  
  I/my parent or guardian filed an income tax return last year.
- The number of individuals currently living in my household and/or claimed as dependents (including myself) is
- My/my parent or guardian’s taxable income for last year was
  (Form 1040 line 43 or Form 1040A line 27)
- Please note that taxable income is different from gross or net income.
- Are you registered with CCCTI Disability Services) Office?
- Do you believe you may have an undiagnosed mental, physical, or learning disability or do you identify yourself as a student with a disability?
- If yes, please explain.
- Have you participated in any of the following TRIO programs?
- If yes, at which school?
- Please write a short statement about your educational goals and career aspirations. In your statement, please also tell us about the services or support you may need in order to achieve academic success and/or graduate.
- I would like to participate in the TRIO/SSS Program and receive the free services provided.
  
  I hereby certify that the information provided in this application is accurate and complete to the best of my knowledge.
  
  I give consent for the TRIO Student Support Services Program to access all of my student records at Caldwell Community College and Technical Institute, including both academic and financial records.
  
  I understand that this information is confidential and will only be used for the purposes of my application to this program.
- Applicant Signature
- Date:
  
  MonthDayYear
  mm-dd-yyyy

TRIO/Student Support Services Program Application