Spoon River College-SSS-Application Form

SRC Student ID*

Application Date:*

mm-dd-yyyy

Name:*

First NameMiddle InitialLast Name

Preferred First Name

Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsOther

Date of birth*

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*

MaleFemale

Ethnicity: Hispanic?*

YesNo

Race (click all that apply):*

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:

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)?:

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)?:

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:

Student Name*

First NameLast Name

Signature Date*

mm-dd-yyyy