Laredo Community College-SSS-Application Form

Semester and Year:

Ex: Fall 2022

Today's Date

Date

Name*

First NameMILast Name

Palomino ID #:*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell:

(999)999-9999

Student E-mail:*

example@students.laredo.edu

U.S. Citizen?*

YesNo

U.S. Permanent Resident?*

YesNo

DOB*

mm-dd-yyyy

Hispanic?

YesNo

Do your parents have a Bachelor’s degree (recognized in the U.S.)?

Father?*

YesNo

Mother?*

YesNo

Race (select applicable):

Race: American Indian/Alaskan Native

YesNo

Race: Asian

YesNo

Race: Black

YesNo

Race: White

YesNo

Race: Native Hawaiian/Pacific Islander

YesNo

Tutoring: Please indicate the subject(s) – choose all that apply

MathematicsBiology/chemistryEnglish/speechHistory/government

PLEASE CHECK ALL THAT APPLY TO YOU:

Participated in TRIO Upward BoundRegistered with Counseling and Disability Services at Laredo College

Did you Participate in TRIO Upward Bound in High School (a TRIO summer and weekend program)?

YesNo

Do you have a registered disability at Laredo College Disability Services?

YesNo

WHICH OF THE FOLLOWING ACTIVITIES ARE YOU INTERESTED IN? (PLEASE CHECK ALL THAT APPLY)

Early Registration & Academic AdvisementAcademic Counseling (e.g. Career, transfer, personal)Financial Aid & Scholarship Application AssistanceTRIO SSS Grant Aid/ScholarshipFinancial Literacy (e.g. Saving, budgeting, credit)TutoringWorkshops (e.g. Resume and Financial Literacy)

Tutoring: Please indicate the subject(s):

Met with (choose one):

Vanessa FilazzolaJesus MolinaLuis Chavez

STATEMENT OF AGREEMENT AND CONSENT:

I certify that the information provided on this application is, to the best of my knowledge, true and correct. If I am determined to be eligible for the program, I will participate in all recommended services and will keep all appointments until my goals are met. I understand that by applying to this program, I authorize Student Support Services to obtain records or data pertinent to my participation from other sources (including, but not limited to, Financial Aid, Special Services, and Registrar’s Office), and to release information as required by law or the terms of the Student Support Services Grant, to the grant-funding agency of the federal government. I give the irrevocable right to use my name, photo, or video in all forms and media and for advertising, trade or anyother lawful purposes, and I waive any right to inspect or approve the finished version(s). I understand that the information will be kept confidential and will be used for reporting purposes as mandated in the SSS Grant.

Student Signature:*

Date:

mm-dd-yyyy

SSS Application Form