Midlands Technical College-Airport & Beltline-SSS-Application Form

Participant Application
ASC 201 / Airport Campus / 803.822.3032 WM 236 / Beltline Campus / 803.738.7841

TRIO Student Support Services (SSS) is funded 100% by the US Department of Education and designed to assist students toward graduation and/or transfer to a 4-year college. A student must be a citizen or permanent resident of the US, enrolled or accepted for enrollment in an associate degree/certificate program, and meet one or more of the following:

1. Is a first-generation college student (neither parent has obtained a four-year degree); OR
2. Meets US Department of Education taxable income level given below; OR
3. Is registered with MTC’s Counseling and Career Services office to receive accommodations
Do you have a degree (Associate’s or Bachelor’s)?*

YesNo
Thank you for your interest in TRiO Student Support Services. You have selected that you have a college degree, unfortunately, TRiO SSS is a federally funded program serving students who are seeking their “First” degree.
How did you hear about our program? *

EmailFriendFacebookInstagramCollege postingClassroom presentation
Friend
Which campus would you prefer to have your intake meeting on?*

AirportBeltline
Participant Information
Student ID*
Student ID*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
mm-dd-yyyy
Age*
Email*
example@example.com
Phone*
(999)999-9999
Gender:*

MaleFemale
Marital Status:*

MarriedSingleSeparatedDivorced
Race: (Please check all that apply)*

American Indian or Alaskan NativeAsianBlack or African-AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhite
Are you a U.S. Citizen or a permanent resident?*

YesNo
Are you a Veteran?*

YesNo
Does either of your parents/guardians have a 4-year bachelor's degree?*

YesNo
Household Income/Financial Aid
Student Support Services (SSS) is required to document all applicants’ taxable income from either the prior tax year or the current tax year. Select the income range for the taxable income for your household or select “did not file.” If you reported your parents’ income on the FAFSA, SSS has a short, signed form you will need your parents to fill out.
Size of Family: (Include everyone in the household that your parents are financially supporting /including yourself)*

12345678
Household Taxable Income: (Line 15, Form 1040) If you filed a tax return and included parent information on your FASA, you must select the combined taxable income range for you and your parents.*

Did Not File$22,590 or lower$22,591 - $30,660$30,661 - $38,730$38,731 - $46,800$46,801 - $54,870$54,871 - $62,940$62,941 - $71,010$71,011 - $79,080
Services Assessment
What services do you need? (check all that apply)*

Academic Counseling (study tips, major, etc.)Personalized AdvisingFinancial Aid CounselingTransfer PlanningAcademic MentoringFAFSA Application AssistanceInformation on financial aid/scholarshipsDisability Information/ReferralWorkshops (time management, etc.)Cultural Enrichment OpportunitiesInformation on 4-year CollegesAssistance with 4-year college applicationsPersonal Finances Information
Career Goals
Describe your educational/career goals.*
Program of Study*
What are your current plans?*

GraduateTransfer to 4-year SchoolGraduate and Transfer
FERPA - Family Educational Rights and Privacy Act (Release of Information)
I hereby grant permission for Student Support Services to transmit and/or request any information about me for the purpose of assistance in verifying income information, making educational decisions and in successfully completing my educational plans. Additionally, I authorize the Counseling and Career Services office of Midlands Technical College to verify that I have provided documentation that registers me as a student with a disability. All of your records will be kept in confidence and in accordance with the Family Educational Rights and Privacy Act (FERPA) of 1974.

I understand the above is necessary to establish my eligibility to receive services from the program. I also understand that completion of this application does not guarantee acceptance into the Student Support Services program.

My signature certifies that the information provided on this application is true and correct to the best of my knowledge. Also, I agree (if requested) to provide documentation, including a copy of my (and/or parental) U.S. income tax return, to verify the accuracy of the information given.
Name*

First NameLast Name
Student’s Signature*

Clear
Student ID*
Student ID*
Date*

MonthDayYear
mm-dd-yyyy
Disclaimer
Midlands Technical College does not discriminate in admissions or employment on the basis of race, sex, national origin or ethnic group, color, age, religion or disability, or military service. The compliance officer for Affirmative Action, Equal Employment Opportunity, and Disability Action can be reached at 803.822.3261.

Participant Application