Hagerstown Community College-SSS-Application Form

Application for TRIO SSS
We are no longer accepting applications

Citizenship/Residency Verification:
Indicate your citizenship status*

U.S. CitizenPermanent ResidentOther

Income Verification:
All applicants are required to submit:
- A signed a dated income statement form which will be provided to the applicant by the TRIO SSS office.
I have read and understand the income verification requirements.*

I have read and understand the income verification requirements.

Students with Disabilities Information:
Do you have a documented disability?*

YesNo
Are you registered with HCC Disability Support Services?*

YesNo
Disability information will be verified with Hagerstown Community College's Office of Disability Support Services.

Applicant Certification:
Applicant Certification:*

This application is a supplement to the required Hagerstown Community College application and in now way replaces the Hagerstown Community College application.I certify that the information in this application is complete and accurate. It is also my understanding that the TRIO SSS staff may exchange academic and financial information with HCC personnel to ensure my academic success.I understand that eligibility does not guarantee admissions to the TRIO SSS program. Further, I understand that preference is given to full-time, degree seeking students, with a GPA of 2.0 or greater.I understand that all applicants must have an academic need as determined by the project director. I understand that I am responsible for adhering to all policies and procedures listed in the current Hagerstown Community College Catalog and Student Handbook.I authorize TRIO SSS staff to gather information (standardized test scores, grade point average, earned credits, transcripts, among other items) concerning my academic progress and financial status prior to my participation in TRIO SSS. I understand this information is used to assist in the determination of my eligibility for the program and it will be kept strictly confidential. I give permission for TRIO SSS staff to gather information for follow-up whenever appropriate, including transfer and progress at four year institutions. I am aware that my eligibility and financial status will be reported to the U.S. Department of Education in accordance with the grant funding regulations. I certify that the information provided on the application is true and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information reported.Finally, I am aware that the personal information provided to the TRIO SSS program will be protected under the Family Education Rights and Privacy Act of 1974. No one will have access to the information unless they work with or for the TRIO SSS program, or are specifically authorized by the student in question to access the information.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Student Publicity Release:
I certify that if I am accepted into the TRIO SSS program, the staff may include my name and/or picture in publications, including the SSS newsletter, website, and social media page(s), which highlight student accomplishments and participation in campus and TRIO SSS activities.
Student Publicity Release:*

Opt-inOpt-out
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Student Text Message Waiver:
The text messages from the TRIO SSS program provides the opportunity to send reminders of tutoring appointments, meetings with SSS staff, special events associated with the program, and/or answers to questions you may ask via text message. There will be no charge from TRIO SSS to use this service, but you may be charged a nominal fee by your carrier to receive text messages (if applicable to my carrier). If you agree, TRIO SSS is not responsible for any charges you may incur from your phone provider as a result of signing up for the TRIO SSS text messages. Should you have questions or concerns regarding your participation in this optional service, you can speak with the TRIO SSS staff as soon as possible.
Text Message Waiver:*

Opt-inOpt-out
Cell Phone Number*
(999)999-999
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Application for TRIO SSS