Cleveland Community College-SSS-Application Form

Application for TRIO Student Support Services
Please fill out the application below as completely and accurately as possible to determine your eligibility for services including tutoring, advising, and usage of other resources.
1. General Information
Name*

First NameMiddle InitialLast Name
Student ID*
Date of Birth*

MonthDayYear
mm-dd-yyyy
CCC Email Address*
example@example.com
Preferred Phone
(999)999-9999
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
(999)999-9999
Cell Phone*
(999)999-9999
Do you text?

YesNo
Preferred Method of Contact

Voicemail on Preferred PhoneVoicemail on Work PhoneVoicemail on Cell PhoneEmailText Messages
Emergency Contact

First NameLast Name
Relationship to You
Emergency Contact's Phone
(999)999-9999
2. Demographic and Eligibility Information
Ethnicity (Check all that apply)

AsianAfrican American/BlackAlaskan Native or American IndianHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOther
Gender

MaleFemaleOther
Citizenship Status

U.S. CitizenNOT a U.S. Citizen
Your Status, if not a citizen
Are you responsible for your home or children?

YesNo
Marital Status

SingleMarriedDivorcedWidowedSeparated
Are you a veteran?

YesNo
Are you a foster child?

YesNo
Are you a homeless or runaway youth?

YesNo
3. Educational Information
Check the highest degree completed:*

High School DiplomaGEDAdult High School DiplomaOther
How many years at Cleveland CC?

First year-never attendedFirst year-attended beforeSecond YearOther
What is your current enrollment status?*

Full time (12 or more credit hours)3/4 time (9 - 11 credit hours)Half time (6 - 8 credit hours)Less than half timeNot yet enrolled
What semester and year did you first enroll at CCC? (e.g., Spring 2010)
Current GPA
What is your expected or declared major/degree?
What is your expected graduation date?

MonthDayYear
mm-dd-yyyy
4. Income Eligibility
You must answer these questions about yourself if you are a financially independent student. Or, if you are under 24 years of age and are a financially dependent student, your parent(s) must answer the following about themselves.
Filing Status*

My family filed a federal income tax return last yearMy family did not file a federal income tax return last year.My family has no TAXABLE income during the last calendar year
My family's TAXABLE income (not total) from the last calendar year was*
$
Does any of your support come from Public Assistance?

YesNo
Are you a financially independent student?

YesNo
Are you a single parent?

YesNo
Number of Children
Have you lived with your parents in the last year?

YesNo
How are you paying for your education?

Pell GrantWork StudySelfParent/GuardianEmployerScholarshipVocational RehabilitationOther
Financial Aid Status

AppliedAwarded/ReceivedNeed to ApplyNo Need to Apply
Of these other sources of income, indicate any you receive:

Child SupportNFTASocial SecurityTAAVA BenefitsVIAWorkFirst
Agencies with whom you are working:

DSSMental HealthServices for the BlindVocational RehabilitationWIAOther
Employment Status*

Employed Full-time (at least 40 hrs per week)Employed Part-time (fewer than 40 hrs per week)Not Employed at this time
5. Family Educational History
Please indicate the highest educational level completed by your mother*

Not a high school graduateHigh school graduate/GED/AHSSome college or Associate DegreeBachelor's Degree or HigherUnknown
Please indicate the highest educational level completed by your father*

Not a high school graduateHigh school graduate/GED/AHSSome college or Associate DegreeBachelor's Degree or HigherUnknown
6. Personal and Miscellaneous Information
Do you have any impairment, disability, or other condition which my require services or accommodations that could better your academic success?

YesNo
If yes, has documentation related to the disability or impairment been submitted to the Disabilities Services Coordinator?

YesNo
Is English your native language?

YesNo
Do you experience any difficulty speaking, writing, or understanding the English language?

YesNo
If you think you may have a disability, impairment, or condition that requires special services or an accommodation that has not been diagnosed, please describe it and share your concerns with us:
How did you hear about our SSS program?

InstructorFlyerClass VisitFriendOrientationOther
Check any other Federal Education Programs that you have participated in.

EOCGear UpSSSTalent SearchUpward BoundOther
What year and through which school/college?
7. Disability Verification Form
Verification from Disability Services Office

If you DO NOT have a disability, you may skip this section.
I have a disability and can provide documentation (i.e. doctor's note or Social Security letter)

I have a disability and can provide documentation (i.e. doctor's note or Social Security letter)
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Please attach a document with your proof of disability here (pdf, doc, docx, jpg, jpeg, png)

Cancelof
Please check here if you cannot submit an attachment and will bring a copy of your proof of disability to the TRIO-SSS office.

Please check here if you cannot submit an attachment and will bring a copy of your proof of disability to the TRIO-SSS office.
Or
Student Attestation Statement

I, {main_name}, ID # {studentId} am identifying myself as a student with a disability and I am NOT requesting accommodations from the CCC Disability Services Office. I do understand that I have to provide proof of disability, such as a doctor's note or Social Security letter.
Please attach a document with your proof of disability here (pdf, doc, docx, jpg, jpeg, png)

Cancelof
8. Service Request Information
Check the services you may need or want.

Academic CounselingTutoringTransfer CounselingCareer CounselingFinancial Literacy (Obtaining aid; managing money)Employability Skills (Resume writing, interview skills, etc.)Personal CounselingStudy Skills DevelopmentCollege TourCultural Trips
Please tell us why you wish to participate in the TRIO-SSS program, and how you think we can help you be successful at CCC.
9. Student Responsibility
I understand the information I've shared will help ensure that TRIO-Student Support Services is complying with federal regulations governing funding for this program. I certify that all the information is correct. Further, I give Student Support Services permission to receive copies of my records from the Financial Aid Office and Student Services. I also give this office permission to obtain information regarding my academic progress from faculty.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
10. AGREEMENT TO PARTICIPATE
As a member of the TRIO-SSS (Student Support Services) program, I {main_name} agree to the participation requirements as explained to me below.

These participation requirements include:
- Attend at least two meetings per semester with my assigned Advisor.
- Keep my assigned TRIO Advisor informed of my progress via personal contact throughout the semester. Appointments are highly encouraged.
- Contact my assigned TRIO Advisor to explore my options and to do a financial aid verification before withdrawing from a course.
- Demonstrate a commitment to graduate and/or transfer by enrolling in courses that are required or recommended for my program of study.
- Maintain at least a 2.0 cumulative (overall) grade point average.
- Participate in at least one TRIO-SSS activity each semester that I am registered at CCC. Example activities include, but are not limited to: workshops, tutoring, college tours, cultural events, or other TRIO-SSS or CCC sponsored activities.
I have read this document, understand it, and agree with the terms and participation requirements.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
11. Photo Release Form
Cleveland Community College

137 South Post Road

Shelby, NC 28152

I grant to Cleveland Community College, its representatives and employees the right to take photographs and/or video of me and my property. I authorize Cleveland Community College, its assigns and transferees to copyright, use, publish, re-use, and re-publish the same in print and/or electronically.

I agree that Cleveland Community College may use such photographs and/or video of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, social media, and web content.

I waive any right I may have to inspect and approve the finished product or copy that may be used in connection with an image or video of me, or the use to which it may be applied.

I release, discharge and agree to save harmless Cleveland Community College, legal representatives and assigns, those for whom they are acting, and all persons or corporations acting with their permission or authority from any liability for any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of the photographs and/or video in any subsequent processing thereof, as well as any publication thereof, including without limitation and claims for libel or invasion of privacy.

I have read and understand the above:
Signature

Clear
Printed Name

First NameLast Name
Email address
example@example.com
Phone
(999)999-9999
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature (if under age 18)

Clear
12. Needs Assessment Survey
Student's Name

First NameLast Name
ID#
Today's Date:

MonthDayYear
mm-dd-yyyy
Check any of the following items which describe you.

Out of school more than 5 yearsAfraid of failing in collegeDifficulty finding childcareOverwhelmed during testsDifficulty meeting new peopleDifficulty meeting deadlinesMy family does not understand college processUnsure of college proceduresDifficulty participating in discussionsFew computer skills, little or no experience on the InternetDifficulty managing money, debtNeed of personal counseling
Check any AND all issues that would most likely prevent you from completing your academic goals.

Poor study habitsPoor Note taking skillsLack of moneyProblems at homeAlways feeling tiredRecurring health concernsTaking things too seriously, always worryingPoor time management skillsBad gradesDealing with billsPersonal support/encouragementTrouble sleepingAfraid to speak up in classBalancing academics and extracurricular activitiesFamily medical programsInternet accessibility at homeTransportationEasily distractedFeeling depressed or sad
What subject areas do you know you may need assistance with?

MathReadingEnglishScienceWriting
Check off any AND all areas you may need assistance with.
Financial:

Personal budgetFAFSAGrants/ScholarshipsDebt management
Personal Issues:

Stress ManagementSubstance AbuseRelationshipsGoals/Decision MakingMotivationStudy skills
Transfer:

Selecting Transfer SchoolApplicationsSearch ProcessFundingPlanning
Career:

Choosing a CareerInterviewingResume/Cover letterCo-op/InternshipLeadership DevelopmentJob Searching
My Academic Goals for this year (include gpa and how you will accomplish it).
Short Term (this semester):
Long term (this academic year):
Describe yourself.
Explain why you selected your major and/or career field (OR if you are undecided) what are your biggest strengths).
Explain why you think you should be considered for the SSS program or how you see the SSS program helping you.
By signing below, I acknowledge that this document has been completed entirely by myself and the information submitted is truthful and will be used in my participation with the program.
Student E-Signature

Clear

Application for TRIO Student Support Services

1. General Information

2. Demographic and Eligibility Information

3. Educational Information

4. Income Eligibility

5. Family Educational History

6. Personal and Miscellaneous Information

7. Disability Verification Form

8. Service Request Information

9. Student Responsibility

10. AGREEMENT TO PARTICIPATE

11. Photo Release Form

12. Needs Assessment Survey