Paris Junior College-SSS-Application Form

TRIO Student Support Services Application
The purpose of our TRIO Student Support Services program is to provide academic support to enrolled Paris Junior College students who meet eligibility requirements to help increase postsecondary education retention and graduation rates. All activities are designed to assist eligible students’ persistence in college from year to year; remain in good academic standing each semester; graduate from PJC; and transfer to a four-year institution. Students selected to be in the TRIO SSS program must meet specific criteria.
PJC Student ID*
Name*

First NameMiddle Initial Last Name
Preferred Name (if different from first name)
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Do you live on campus?*

YesNo
Cell Phone Number*
(999)999-9999
Please indicate if TRIO SSS staff can text you regarding your application status and any future notifications. Standard message and data rates may apply.*

YesNo
PJC Email Address*
example@example.com
Personal Email Address*
example@example.com
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemale
What is your race and/or ethnicity? (check all that apply)*

American Indian or Alaskan NativeAsianBlack or African-AmericanHispanic or Latino of any raceWhiteNative Hawaiian or Pacific IslanderOther
Are you a U.S. Citizen or Permanent Resident?*

YesNo
Please provide your USCIS#*
At any time since you turned age 13, were both your parents deceased, were you in foster care, or were you a dependent or ward of the court?*

YesNo
Did either parent or guardian complete a 4-year college degree?*

MotherFatherBothNeither
What is your current enrollment classification at Paris Junior College?*

Incoming First Year/FreshmanSophomoreIncoming TransferContinuing Student at PJC
Please select your financial aid student type*

Dependent StudentIndependent Student (are married, have a child or other dependents, are in active duty or a veteran, are aged 24 and above, were in foster care/ward of the court/or an emancipated minor)
Number of family members living in household last year?*

12345678+
Do you have a documented disability?*

Yes - on file with Paris Junior College ADA officeYes - not on file with Paris Junior College ADA officeNo
What services are you interested in receiving through TRIO SSS? (select all that apply)*

Academic and Career AdvisingFinancial Aid Assistance/InformationTutoringTransfer AssistanceStudy Skills/Time ManagementCultural EventsCareer ExplorationFinancial and Economic Literacy/BudgetingProfessional and Peer MentoringOther
Please indicate if you were in a previous TRIO program (select all that apply)*

Educational Opportunity CenterStudent Support ServicesTalent SearchUpward BoundUpward Bound Math-ScienceNone of the above
Attachment S Statement:

Paris Junior College TRIO Student Support Services Program is federally funded by U.S. Department of Education. PJC-SSS annually serves 140 participants who are from low-income backgrounds, first generation college students and participants with disabling conditions, with a budget of $261,888.
Is English your first language?*

YesNo
What is your native language?*
Did either parent complete a 4-year degree from a college or university?*

MotherFatherBothNeither
Are you a high school graduate?*

YesNoGED Certificate
What high school did you attend?*
What year did you graduate high school?*
From what state did you obtain your GED?*
What year did you receive your GED?*
Which Paris Junior College degree or certificate are you planning to pursue?*

Associate of Arts (AA) ProgramAssociate of Science (AS) ProgramAssociate of Applied Sciences (AAS) ProgramCertificate Program
What is your major/program of study?*
Do you plan to transfer after graduation from Paris Junior College?*

YesNo
What is your intended transfer university?*

Texas A&M University - CommerceTexas A&M University - TexarkanaUniversity of North Texas - DentonUniversity of Texas - ArlingtonOther
Have you applied for financial aid at Paris Junior College? (select the most recent FAFSA completed)*

Yes - completed FAFSA for 2022-2023 academic yearYes - completed FAFSA for 2023-2024 academic yearNo - I have not completed a FAFSA
What types of financial aid are you receiving? (select all that apply)*

GrantsLoansScholarshipsWork StudyNone
Are you now or have you ever been on financial aid probation or suspension?*

YesNo
Student Personal Statement
For this response, you will have the opportunity to let us know a little more about yourself. Please answer the questions below. Feel free to add any other information that you feel is relevant to our decision in choosing you as a Student Support Services participant. This is a very important part of the application process. In 200 words or less, explain the following:
1. Why do you want to join the TRIO SSS program?
2. What barriers do you feel may hinder your educational success?
3. What kind of job do you want to secure after you graduate from Paris Junior College and why?
4. List three personal goals you hope to complete this year.
These questions do not need to be answered in order, but please make sure to address each one in your statement below.*
How did you hear about TRIO Student Support Services? (select all that apply)*

Blackboard AnnouncementPoster/FlyerClassroom PresentationProfessor/Faculty/StaffReferred by TRIO SSS ParticipantReferred by Financial Aid OfficeReferred by Advising & Counseling OfficeReferred by Disability OfficeParis Junior College WebsiteOther
Release of Information
I declare under penalty of perjury that the information on this form is true to the best of my knowledge.

Pursuant to 20 USA 1231a of the U.S. Department of Education, TRIO SSS at PJC is authorized to access information deemed necessary to assist me in achieving my educational goals or in meeting the reported requirements of the U.S. Department of Education, to record pertinent facts regarding my eligibility in the program, services rendered, and postsecondary education. This information is protected by the Privacy Act, kept confidential and not be seen unless specifically authorized. A copy of this statement shall serve as such authorization. I authorize TRIO SSS personnel to conduct and communicate information pertaining to my educational outcomes and to fulfill program reporting requirements as they relate to the TRIO SSS project using phone, email, text messaging or other digital mediums. I authorize use of my photograph in TRIO publications and media releases to include my photograph appearing on social media platforms to demonstrate implementation of grant objectives. I authorize TRIO SSS to obtain any records from the PJC Financial Aid Office that may pertain to my participation in the SSS program.

I will contact Disability Services independently if I would like to participate in TRIO activities and require accommodations. I understand that submission of this application does not guarantee acceptance in the TRIO program.
Type Name:*

First NameLast Name
Date:

MonthDayYear
mm-dd-yyyy
Signature*

Clear

TRIO Student Support Services Application

Student Personal Statement

Release of Information