Spoon River College-SSS-Application Form

Spoon River College-SSS

Application Form
Permission to Release

Student Record Information
Subject to certain exceptions set forth in the Federal Family Education Rights and Privacy Act (FERPA) of 1974, Spoon River College (SRC) will not provide personally identifiable student information (including but not limited to grades, billing, tuition and fees, assessments, financial aid and other student records) to third parties absent the student’s consent. Third parties include parents, spouses and third-party designees.
I, ______________________________,

First NameLast Name
SRC Student ID:
give permission for Spoon River College to release the following information to:
Spoon River College TRIO-SSS

Financial Aid Information (Information includes: required documentation or missing documents, financial aid awards such as Pell, MAP, and/or SRC Foundation Scholarships, Standards of Progress, and student loan information and amount.)Other FTI (Federal Tax Information)
The above-named individuals or organizations will need to request the information each time it is needed. I understand that this release will remain in effect for as long as I am a student at Spoon River College, or until revoked by me.
Electronic signature:

Clear
Date:

MonthDayYear
Date
I decline the request to disclose my financial aid information to Spoon River College TRIO-SSS.

I decline the request to disclose my financial aid information to Spoon River College TRIO-SSS.
SRC Student ID*
Application Date:*

MonthDayYear
mm-dd-yyyy
Name:*

First NameMiddle InitialLast Name
Preferred First Name
Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsOther
Date of birth*

MonthDayYear
mm-dd-yyyy
Local Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
(999)999-9999
SRC Email:*
example@example.com
Other Email:
example@example.com
Preferred Contact Method

Phone callEmailText messageCanvas message
Sex assigned at birth*
Sex assigned at birth*

MaleFemale
Ethnicity: Hispanic?*

YesNo
Race (click all that apply):*

African-American/Black/AfricanAmerican Indian/Alaskan NativeAsian American/AsianCaucasian/WhiteHispanic/Latino/LatinaNative Hawaiian/Pacific IslanderOther
Are you a U.S. citizen or permanent resident?*

YesNo
What is the highest level of education achieved by your parent or guardian? If your parents are/were divorced and you resided with them until you were 18, reply only in regards to the parent who had primary custody:
Father/Guardian Education*

High School Diploma/GED/State of Illinois High School Diploma2 year degree/Associate degree4 year degree/Bachelor degree and beyondOther
Mother/Guardian Education*

High School Diploma/GED/State of Illinois High School Diploma2 year degree/Associate degree4 year degree/Bachelor degree and beyondOther
Do you have a documented disability with Spoon River College?*

YesNo
High School Graduation Status*

High School DiplomaGED/State of Illinois High School DiplomaNot applicable
Institution and date received:
Have you earned any degrees or certificates previously?

YesNo
If yes, mark all that apply:

CertificateAssociate's DegreeBachelor's DegreeMaster's Degree
Have you completed a FAFSA (Free Application for Federal Student Aid) for the current year?

YesNo
Type of financial aid you receive:

Pell GrantMAP GrantLoansWork StudyTalent GrantWorkforce Investment Act(WIOA)or Career LinkMilitary BenefitsUnsure/Don't KnowOther
Military Benefits (please specify):
Talent Grant (please specify):
Scholarships (please specify):
Are you a part of a Spoon River College athletic team?:
If yes, please specify team:
Which Spoon River College campus are you taking classes at (Check all that apply)?:

CantonMacombRushvilleHavanaOnline
Do you plan to transfer to a 4-year college after SRC to obtain a degree?

YesNo
What is your career plan after graduation?:
How did you find out about the TRIO-SSS Program?
What services are you looking for from TRIO SSS (check all that apply)?:

Academic advising/choosing coursesFinancial Aid and scholarship helpPersonal budgeting/financeCultural tripsComputer lab/printing4 year transfer assistanceMath tutoring4 year campus visitsAcademic/Personal enrichment workshopsTextbook library4 year college application waiversCareer guidanceTRIO ScholarshipLaptop lendingPeer tutoring
The above information is true and complete, to my knowledge. I understand it is confidential and will be used for intake purposes. Further, I release the following information to TRIO-Student Support Services to verify eligibility, determine appropriate services, and to track academic progress: mid-term and final grades, transcripts/registration information, financial aid information, standardized test scores (ACT/SAT/COMPASS/ACCUPLACER, etc.), income information, transfer information, and contact instructors/advisors. Providing my cell phone number enrolls me in the texting program that I can opt out of at any time, TRIO nor SRC are responsible for any texting charges. I understand completion of application does not guarantee acceptance to the SRC TRIO-SSS program. I understand the TRIO Director reserves the right to admit or deny any student’s acceptance to the SRC TRIO-SSS program. Students are accepted into the program on a first come, first serve basis and is based on eligibility criteria outlined by the Department of Education that provides grant funding for the program.
Electronic Signature:

Clear
Student Name*

First NameLast Name
Signature Date*

MonthDayYear
mm-dd-yyyy

Spoon River College-SSS

Permission to Release