Jefferson College District Of Jefferson County-SSS-2023 Application Form

Application
PERSONAL DATA
Name*

First NameMILast Name
Student ID #:
V_____________
Date of Birth:

MonthDayYear
mm-dd-yyyy
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
(999)999-9999
Cell Phone:
(999)999-9999
Primary #:

HomeCell
Do we have your permission to send you text messages:

YesNo
Jeffco E-mail Address:*
example@example.com
Individual E-mail Address:
example@example.com
Gender:

MaleFemale
U.S. Citizen:

YesNo
Veteran:

YesNo
Foster Child:

YesNo
Currently without a permanent residence:

YesNo
Primary Language Spoken:
Ethnicity: Are you Hispanic/Latino:

YesNo
Race: (please check all that apply)

American Indian/Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian/Other Pacific IslanderOther
ELIGIBILITY DATA
Did either of your parents/adoptive parents obtain a four-year (Bachelor’s) degree?

YesNo
Do you have a documented disability?

YesNo
If yes, are you working with Jefferson College Accessibility Resource Office (ARO)?

YesNo
Have you applied for financial aid (completed a FAFSA)?

YesNo
Do you have any student loans?

YesNo
EDUCATIONAL DATA
High School attended:
Year High School Diploma or GED/HiSET was earned:
Do you plan to graduate from Jefferson College with a degree and then transfer to a 4 year college?

YesNo
Do you plan to transfer to another college without graduating with a degree from Jefferson College?

YesNo
College Major/Field of Study:
Anticipated Transfer Institution:
Highest level of education you would like to pursue:

CertificateAAS DegreeAssociate's DegreeBachelor's DegreeMaster's DegreeP h.D.
CONCERNS
Check all items that are of concern to you:

Uncertain academic/career goalsTransportation problemsWork demands that conflict with academic goals (# of hours worked per week: ____)Lack of money to meet educational, living and personal needsFamily issues interfering with academic achievementSucceeding in classesDisability concerns:Other
Disability concerns:

SelfFamily member
Disability concerns: Self
Disability concerns: Family member
SERVICES
Check any services that you are interested in:

Academic AdvisingAcademic SupportCultural EventsDisability SupportFinancial Aid AssistanceInformational WorkshopsLeadership DevelopmentPersonal SupportTransfer AssistanceTutoring
HOW DID YOU FIND OUT ABOUT THIS PROGRAM?

COL101Family MemberFriendProject SUCCESS ParticipantProject SUCCESS StaffClassroom VisitOther College Employee:Other/Name:Viking Ready Orientation
Other College Employee:
Other/Name:
PREFERRED APPOINTMENT METHOD?
PREFERRED APPOINTMENT METHOD?

Virtual AppointmentIn-Person AppointmentPhone Appointment
AGREEMENT
I understand the SSS Program will use the data provided on this form to assist in assessing any academic and/or career planning needs and all information will be kept confidential according to FERPA laws. I hereby authorize the release of appropriate educational, financial aid, income, personal, disability documentation and other information as deemed necessary by the Director of Student Support Services for official use at Jefferson College.

I certify the information on this application is true and accurate to the best of my knowledge.
Opt-in/opt-out of signing electronically

Sign electronicallyManually in the office
Print (full name):

First NameLast Name
Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Student Support Services-Project SUCCESS is 100% federally funded by the U.S. Department of Education in the annual amount of $318,277.

Student Support Services serves first-generation, low-income, and students with documented disabilities and provides services to support participants

in earning their associate degree and transferring to a four-year institution.

1000 Viking Drive • Hillsboro, MO 63050 • www.jeffco.edu/projectsuccess

It is the policy of Jefferson College that no person shall, on the basis of age, ancestry, color, creed, disability, genetic information, marital status, national origin, race, religion, sex, sexual orientation, or veteran status, be subject to discrimination in employment or in admission to any educational program or activity.
Note: If accommodations for a disability are needed contact the
Accessibility Resource Office – Technology Center 101, (636) 481-3158 or 797-3000, ext. 3158 or email: aro@jeffco.edu.

Application

PERSONAL DATA

ELIGIBILITY DATA

EDUCATIONAL DATA

CONCERNS

SERVICES

PREFERRED APPOINTMENT METHOD?

AGREEMENT