Lone Star College-North Harris-SSS 2-Application Form

Lone Star College North Harris TRIO Student Support Services
Application Checklist Items
- Complete every line item in the application.
- Sign and date the application.
- Ensure that the income verification form is complete and signed.
You will also need to provide:

1. Two Forms of Identification
- State-issued Driver’s License/ID Card
- Permanent Resident Card
- Passport or Passport Card
- Social Security Card
- Birth Certificate
TRIO SSS is a 100% federally funded program under the U.S. Department of Education.
Affirmative Action/EEO College
Identification 1

Cancelof
Identification 2

Cancelof
Name:*

First NameLast Name
Student ID:
Social Security #:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:
(999)999-9999
Home Phone Number:
(999)999-9999
Birth Date:

MonthDayYear
mm-dd-yyyy
Age:
Email Address:*
example@example.com
Ethnicity:

African-AmericanAsianCaucasianHispanicOther
Multi-ethnic (More than One):
Citizenship:

U. S. CitizenPermanent ResidentOther
Gender:

MaleFemaleOther
Are you registered with our Disability Services Office?

YesNo
Did Parent 1 graduate from college with a 4-year degree?

YesNo
Did Parent 2 graduate from college with a 4-year degree?

YesNo
Are you receiving financial aid?

YesNo
If yes, are you considered an:

Independent StudentDependent StudentDon’t Know
If No, check the reason(s):

Have Not AppliedWas Not EligibleOther
Current Classification:

Incoming FreshmanFreshmanSophomoreReturning Student
Current Course Load:

Full-time StudentPart-time StudentLess than Part-time
Disability Services Verification:

Section 12102 of the Americans with Disabilities Act (42 U.S.C. 12101 et seq.), defines a person who has a disability as, “… a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment.”

I certify that I am an individual with a disability as defined above.
Student Signature

Clear
When was your first semester at LSC-North Harris?
Month:
Year:
Number Of Course Hours Completed At LSC So Far:
Cumulative GPA:
If you don't know, please type "Don't Know"
What Are Your Current Educational Plans?

Certificate/Diploma OnlyTransfer OnlyGraduate with Associate Degree OnlyGraduate & TransferDon’t Know
I certify that all the information on this form is true and complete to the best of my knowledge. I also authorize the LSC North Harris SSS Project permission to obtain and review any academic and financial documents needed to complete the application process.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
NEEDS ASSESSMENT
What is your educational and career goal?
If undecided, please type "Undecided"

Please indicate the subject(s) that you may need tutoring in?

	Subjects
a)
b)
c)

What days are you available to attend tutoring sessions (check all that apply)?

MonTuesWedThursFri
Did you successfully test into college level math?

YesNo
Did you successfully test into college level English?

YesNo
Are you currently employed?

YesNo
If so, how many hours are you working per week?
What can TRIO Student Support Services do to help you succeed? (Check all that apply):

4 year College VisitsAcademic AdvisingAcademic preparedness for collegeAcademic support to raise gradesAssist w/ Educational/Career GoalsConfidence, Social Skills BuildingDegree Plan AdvisingFinancial Aid AdvisingFinancial Literacy/PlanningInterview TechniquesLeadership DevelopmentLow Admission Test ScoresLow College Grades/AdvisingObtaining InternshipsScholarship AssistanceSelecting Courses for Degree PlanService LearningSTEM Careers InfoStudy/Note Taking SkillsTest Taking SkillsTime ManagementTransfers Admissions Advising
What obstacles do you feel would prevent you from successfully completing your goals?
Who or what campus service referred you to our program?
Application completion checklist:

Completed & signed applicationIncome Verification DocumentationLone Star College Unofficial Transcript
Income Verification Form
Name

First NameLast Name

Household Size Information:

	Full Name	Relationship
1
2
3
4
5
6
7
8
9
10

Taxable Income:
You can find this number on your parent’s most recent Tax Return. If you are considered an Independent Student, this will be on your own Tax Return

-For your 2022 Tax Return you can find “Taxable Income” on your 1040 Tax Return.
Student Signature:

Clear
Date

MonthDayYear
mm-dd-yyyy
Parents Signature:

Clear
Date

MonthDayYear
mm-dd-yyyy
(Parent signature needed If you are considered a Dependent student. If you filed a FAFSA, check your status to determine if you are considered a Dependent or Independent student)

(We certify that this statement is true and correct to the best of our knowledge.)

Lone Star College North Harris TRIO Student Support Services