Passaic County Community College-SSS-Application Form

PASSAIC COUNTY COMMUNITY COLLEGE

Student Support Services Program Application
- Name:*
  
  First NameLast Name
- PCCC ID:
- DOB:
  
  MonthDayYear
  mm-dd-yyyy
- Gender:
  
  MALEFEMALEOther
- Home Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- County:
- Cell Phone:
  (999)999-9999
- Home Phone:
  (999)999-9999
- PCCC Email:*
  example@students.pccc.edu
- Other Email:
  example@example.com
- Please attach a copy of your ID
  
  Cancelof
- Ethnicity:
  
  Hispanic or LatinoNot Hispanic or Latino
- Ethnic/Racial Background:
  
  Hispanic or LatinoBlack or African AmericanAsianWhiteNative Hawaiian or other Pacific IslanderAmerican Indian or Alaskan Native
- The information requested on race, ethnicity and sex is not used in the selection process. It is set aside and used in reports to the Department of Education in Washington D.C. It is the policy of the Student Support Services program not to discriminate on the basis of sex, race, religion, color, national origin, age and disability in its decisions
- Do you have a documented disability?
  
  YesNo
- Are You a U.S. Citizen?
  
  YESNO
- Are you a Permanent Resident of the United States?
  
  YesNo
- Have you completed an Associates or Bachelor’s degree from any college or university?
  
  YesNo
- Did either of your parents/guardians with whom you reside Graduate from a College with a 4-Year Bachelor’s Degree?
  
  YESNO
- Programs you have participated in (indicate all that apply):
  
  Upward BoundTalent SearchGEAR UPEducational Opportunity Fund (EOF)Student Support Services
- Where?
- Are you a Transfer Student?
  
  YesNo
- If yes: Name of Institution
- Current or Intended Major of Study:
- What is your educational goal at PCCC?
  
  Associate DegreeCertificate
- To provide income information, choose the option that applies to you.
- If you are a dependent student, please use your parent/guardian's most recent income tax information and your own income information (if applicable). I am including my/my parents’ income information.
  
  YesNo
- If you are an independent student, please provide your own income tax information. I am including my income tax information.
  
  YesNo
- I am including my signed FAFSA Student Aid Report (SAR).
  
  YesNo
- Dependent/Independent Form
- If you or your family did not file an income tax return last year, please indicate a need to complete the Program’s Dependent/Independent Income Verification form provided by our office. I am requesting a Verification Form.
  
  YesNo
- Number in Household:
- Family's Taxable Income*:
  $
- Student's Taxable Income*:
  $
- My family did not file income taxes:
  
  My family did not file income taxes
- *Please submit your Family’s most recent Income Tax Return, showing Taxable Income (On Form 1040, line 15) *
  
  Cancelof
- What types of services would help you successfully reach your academic goals? (Indicate all that apply):
  
  Academic CoachingCareer ExplorationCultural Enrichment ActivitiesLeadership OpportunitiesFinancial Aid InformationTransfer PlanningScholarship OpportunitiesMentoringAcademic TutoringStudy Skills Workshops
- I give Passaic County Community College and the TRiO Student Support Services Program, permission to record the image and/or voice of myself as named. I grant Passaic County Community College all rights to use sound, still, or moving images in any medium for educational, promotional, advertising, or other purposes that support the mission of the college.
- Please select:
  
  YesNo
- Initials
- If selected, upon my acceptance to the TRiO Student Support Services program, I agree to fulfill all my requirements as a program Scholar and be committed to my academic and personal achievements at Passaic County Community College. I also agree to the following:
  - I will meet with my TRiO Student Support Services Counselor, one time each month during the fall and spring semester throughout my academic career at PCCC to review my progress.
  - I agree to participate in workshops and activities provided by Student Support Services and will attend at least two (2) workshops during each semester.
  - I must attend tutoring sessions during the semester in the SSS Learning Center (A-223), if referred by my counselor.
  - I agree to register and maintain at least 9 and successfully complete a minimum of 24 credits each academic year.
  - I accept the responsibility for acquainting myself with registration, withdrawal, and refund policies and procedures set forth in the current PCCC Catalog and Schedule.
- Please select:
  
  YesNo
- Initials
- I, hereby certify that all answers and information provided, constitute a full and complete disclosure with respect to this application. I understand that this application is being made in connection with the receipt of federal funds, and the U.S. Federal Government and the U.S. Department of Education may verify this information.
- Student Signature:
  
  Clear
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Parent/Guardian Signature:
  
  Clear
- (If providing parent’s Income Tax, please have them sign above)
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- I authorize use of my name and photograph to be published in Student Support Services' publications. I also certify that all of the above information is correct. Completion of the application does not guarantee acceptance into the program.
- STUDENT SUPPORT SERVICES -
  
  Passaic County Community College
  
  Founders Hall, Room E204
  
  One College Boulevard, Paterson, NJ 07505
  
  Office Phone: 973-684-7170
  
  Email: sss@pccc.edu

PASSAIC COUNTY COMMUNITY COLLEGE