Luther College-SSS-Application Form

TRIO Achievement Program - Application

Please complete the fillable application, or if printing application, write legibly. Application must be complete to be considered. Thank you for your interest in TRIO!
Student Information
Date:*

MonthDayYear
mm-dd-yyyy
Citizenship:*

US Citizen OR Permanent ResidentNoOther
Please Explain:
Name:*

First NameMiddle NameLast Name
Preferred Name
Luther I.D.:*
Permanent Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
(999)999-9999
Student Cell Phone Number:*
(999)999-9999
Luther Email Address:*
example@example.com
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Demographics
Gender:*

MaleFemaleTransgenderNon-Binary/Non-ConformingPrefer not to respond
Preferred pronouns:
Marital Status:*

SingleMarriedSeparatedDivorcedWidowed
Race (please mark all that apply)*

American Indian/ Alaskan NativeAsianBlack/ African AmericanNative Hawaiian or other Pacific IslanderWhiteOther, please specify:
Ethnicity*

Hispanic/LatinoNot Hispanic/Latino
Eligibility
Do you have a documented physical and/or learning disability that you may have received accommodations in high school, such as a 504 or IEP?

YesNo
Are you registered with Luther College Disability/Accessibility Services?

YesNo
If you received accommodations in high school, which support did you receive?

504IEPNone
The term “first generation college student” refers to a college student whose parent(s)/guardians(s) did not complete a bachelor’s or 4-year college degree. According to this definition, are you a first-generation college student?*

YesNo
What is the highest educational level or grade your parents/guardians completed? Check one for each person. Parent/Guardian 1

High School/GED/HiSETSome collegeAssociate's DegreeBachelor's DegreeGraduate Degree (Masters, PhD, MD, JD, etc)Unknown
What is the highest educational level or grade your parents/guardians completed? Check one for each person. Parent/Guardian 2

High School/GED/HiSETSome collegeAssociate's DegreeBachelor's DegreeGraduate Degree (Masters, PhD, MD, JD, etc)Unknown
Currently reside with:*

Parent/Guardian 1Parent/Guardian 2BothNeither
Have you ever participated in a TRIO Program?

YesNo
If yes, please select:

Upward BoundTalent Search
Active Dates/Semesters:
Enrollment Information
Are you currently enrolled at Luther?

YesNo
Date started at Luther
MM/YYYY
Class Level:

First YearSophomoreJuniorSenior
Are you or will you be transferring to Luther?

YesNo
Previous college or university:
What is your proposed major? (ex. Sociology, History, Education):
What is your intended area of study? Put “Undecided” if you are exploring options.
What is your anticipated graduation date? Semester/Year:
MM/YYYY
Income Verification
Have you completed the FAFSA form?*

YesNo
Academic Year
Are you currently receiving or will you qualify for a Pell Grant? *

YesNoUnsure
Dependent Student: You are considered dependent if you do not meet one or more of the criteria for independent status.

Independent Student: A financially independent student must meet one of the following criteria:
- at least 24 years old by Dec.31
- orphan or ward of the court at 18 years old
- married
- veteran or active duty military
- have legal dependents
- homeless as a minor
For federal financial aid purposes, are you considered a Dependent or Independent student?*

Dependent StudentIndependent Student
The TRIO Student Support Service program will verify your income eligibility for program participation by using the FAFSA data on file with the Luther College Financial Aid Office. Alternatively, you can disclose your family’s taxable income for the preceding year.

OPTIONAL DISCLOSURE
Family size in household, including yourself for the preceding year (this includes everyone living in the home):
Tax Year:
Family Taxable Income (line 15 on standard 1040 form():
Parent/Guardian Name (if Dependent)

First NameLast Name
Parent Signature (if Dependent)

Clear
Date

MonthDayYear
Date
Family size in household, including yourself (this includes everyone living in home).
We need to verify your income. Please choose one of the following that you prefer for us to verify income:

FAFSA data on file with Luther College Financial Aid OfficeMy parent/guardian and I respectfully decline to provide a copy of our tax return for the most recent tax year but will report taxable income that is listed on the income tax return for the most recent tax year.
Tax Year
Family Taxable Income (Line 15 on Standard 1040 Form)
Enter taxable income if options 3 or 4 above were selected:
Parent/ Guardian PRINTED Name (if Dependent)

First NameLast Name
Parent/Guardian SIGNATURE (if Dependent)

Clear
Date:

MonthDayYear
mm-dd-yyyy
Needs and Goals
All students enrolled in TRIO must demonstrate an academic need. Please check all items that apply. You must check at least ONE to be eligible for this program. Low college readiness indicator (GPA, SAT, ACT test score)

Lack of educational and/or career goalsConditionally admitted to Luther CollegeCurrently failing a class or have a low grade(s)Currently on academic probation at Luther (not applicable for incoming students)Undecided educational and/or career goals (still deciding between options is fine - let us know by checking this box)Have unmet financial needA non-traditional college student (out of school for a minimum of 5 years)Low high school gradesNeed for academic support to raise grade(s) in required course(s) academic majorSeeking a professional program, such as (medicine, pharmacy, dental, nursing, law school, veterinarian, etc.)Lack of academic preparedness for college level course workWork more than 20 hours/week during the academic year.
Share 3 goals you wish to accomplish as a college student:
Select the areas below that you would like to improve:

Math SkillsWriting SkillsReading SkillsListening SkillsConcentrationMemorizationStudy SkillsTest TakingNote TakingTime ManagementComputer SkillsProcrastination
The TRIO Student Support Services Program offers support in many areas; check the services that would be most useful to you:

Academic Planning/Course SelectionChoosing a MajorCareer GuidanceFinancial Aid/Scholarship AssistanceStress ManagementPeer MentoringGroup/Study/Support SessionsCampus Resource InformationGraduate School GuidanceTime Management/Study AssistanceFinancial LiteracyCultural Enrichment
Share 3 goals you wish to accomplish as a college student:
READ ME

I would like to participate in the TRIO Student Support Services (SSS) Program and receive the free services provided. I hereby certify that the information provided in this application is accurate and complete to the best of my knowledge. I give consent for TRIO to access all my student records at Luther College, including academic and financial records. In addition, I give consent to the TRIO staff to share my information with other staff, faculty, mentors and professionals if it will assist with my academic success.

I understand that completion of this form does not guarantee acceptance into TRIO. If accepted into the TRIO program, I understand I must meet the program requirements and remain an active participant. Failure to follow program requirements may result in removal from the TRIO SSS Program.

I understand that communication, engagement and representation are important parts of TRIO. To that end, I grant permission to TRIO to use my name, picture and/or likeness for marketing purposes, including but not limited to the website, publication, social media and presentations. I understand that by signing this application I am also authorizing TRIO to contact me via phone, email and text message.
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
It is the policy of Luther College to provide equal educational opportunities and equal access to facilities for all qualified persons. The College does not discriminate in employment, educational programs, and activities on the basis of race, color, ethnicity, national origin, age, sex, sexual orientation, gender, gender identity or expression, genetic information, veteran status, religion, disability, creed or any other protected class as defined by state or federal law. Sexual harassment and sexual assault are prohibited forms of sex discrimination under Title IX of the Education Amendments of 1972.

The Luther College TRIO Achievement Program is a federally funded U.S. Department of Education TRIO program.

TRIO Achievement Program - Application

Student Information

Demographics

Eligibility

Enrollment Information

Income Verification

Needs and Goals