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

Name*

First NameMILast Name

Student ID #:

V_____________

Date of Birth:

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)

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

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:

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

Check any services that you are interested in:

HOW DID YOU FIND OUT ABOUT THIS PROGRAM?

Other College Employee:

Other/Name:

PREFERRED APPOINTMENT METHOD?

Virtual AppointmentIn-Person AppointmentPhone Appointment

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:

Date:

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