Western Nebraska Community College-SSS-Application Form

Western Nebraska Community College TRIO Student Support Services Application
All answers are confidential and reported as group data for program documentation and eligibility purposes only.

Incomplete applications will not be processed.
PERSONAL INFORMATION:
Name:*

FirstMILast
Preferred Name:
Previous Name:
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #:*
(999)999-9999
Alternate Phone #:
(999)999-9999
Are you willing to receive text messages about events?

YesNo
WNCC Email Address:*
example@wncc.edu
Other Email:
example@example.com
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Last 4 of SSN:
OR
Student ID:
Gender*

FemaleMaleNonbinary or Another Gender
Gender Identity:
Pronouns:
Ethnicity: Hispanic or Latinx?*

YesNo
Race: Select one or more races that apply among the following:*

American Indian or Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or Other Pacific Islander
Citizenship:*

US CitizenUS NationalMeet residency requirements for federal student aidUnsure
Campus you are attending (check all that apply):*

ScottsbluffAllianceSidneyOnline
EDUCATIONAL HISTORY & OCCUPATIONAL GOALS:
Do you need assistance to enter the workforce due to limited marketable skills?*

YesNo
Are you a high school graduate?*

YesNo
If "Yes", what year did you graduate?
Did you receive a GED?

YesNo
If "Yes", what year did you receive your GED?
Do you already have a college degree? (If you have an associate’s degree or higher, you are NOT eligible for services.)*

YesNo
If yes, what degree?

MA/MSBA/BSAA/ASAAS
Long-Term Educational Goals (Priority is given to students who plan to pursue an Associate's Degree and/or transfer to a 4-year college):*

DiplomaOne-year CertificateTwo-Year CertificateAssociate's DegreeBachelor's DegreeMaster's DegreeDoctoral Degree/Law Degree/Medical Doctor Degree
What is your major?*
Career Goals?
ADDITIONAL INFORMATION:
Are you a veteran?*

YesNo
Are you a parent?*

YesNo
Are you a single parent?

YesNo
ELIGIBILITY FOR SINGLE PARENT IN NETWORK PROGRAM (SPIN) SERVICES: Please check all boxes that apply to you:

Single parent and/or displaced homemaker: A single parent must have sole or joint custody of a minor/disabled child or children. A displaced homemaker is a parent who stayed home to raise a child(ren) and/or did not work outside the home for a period of four or more years and is currently divorced, separated, widowed, or whose spouse is disabled.Newly enrolled studentCurrently enrolled student with a 2.0 or higher GPA. (required for SPiN financial assistance)
Marital Status (please select one):

SingleDivorcedWidowedMarried with a disabled partner

PARTICIPATION AGREEMENT:

By signing the TRIO application, I agree to adhere to and maintain the following standards to be considered eligible for SPiN services:
- Maintain a cumulative GPA of 2.0 or above (newly enrolled students have limited financial assistance until their GPA is established).
- You agree to meet with your assigned program advisor twice per semester.
Referred by:

Student/FriendProfessorWNCC DepartmentOther
If referred by a Student/Friend, Professor, or WNCC Department, please specify below:
ELIGIBILITY FOR SERVICES:
Did a parent/adoptive parent complete a 4-year college degree before your 18th birthday?*

YesNo
If yes, did that parent raise you more than 50% of the time?*

YesNo
Do you have a disability as defined by Section 504 of the ADA (including a military disability)?*

YesNo
Did you apply for Financial Assistance (FAFSA)?*

YesNo
If yes, did you qualify?*

YesNoUnsure
Is your taxable family income at or below the limits in the chart below?*

YesNoUnsure
For family units with more than eight members, add the following amount for each additional family member: $8,070 for the 48 contiguous states, the District of Columbia, and outlying jurisdictions; $10,095 for Alaska; and $9,285 for Hawaii. The term “low-income individual” means an individual whose family’s taxable income for the preceding year did not exceed 150 percent of the poverty level amount. The figures shown under family income represent amounts equal to 150 percent of the family income levels established by the Census Bureau for determining poverty status. The poverty guidelines were published by the U.S. Department of Health and Human Services in the Federal Register on January 17, 2024, and are effective as of January 11, 2024.
SKILL/NEED SELF-ASSESSMENT:

Utilizing the following scale, check the response that best reflects you as a college student:*

	Poor	Fair	Average	Above Average	Excellent
Motivation
Self-Discipline
Self-Esteem
Confidence
Perseverance
Intellectual Interest
Study Habits
Attitude Toward College
Sense of Financial Security
Math Skills
Science Skills
Reading Skills
Writing Skills
Foreign Language Skills
Computer Skills

Check the response best reflects your perception of your abilities in each of the following areas: *

	Poor	Fair	Average	Above Average	Excellent
Math
Science
Reading
Writing
Foreign Language
Computer Skills

Which of the following services would you utilize in the WNCC TRIO SSS Program? (check all that apply):*

Tutoring ServicesPersonal Finance Management4-Year College VisitsCultural Enrichment ActivitiesAssistance in Completing & Applying for Federal Student Aid (FAFSA)Coaching (test taking, note taking, study skills, time management, etc.)Grammarly PremiumAssistance with Campus ResourcesAdvising (setting goals, career guidance, course selection, understanding degree requirements, stress management, etc.)
Which of the following skills workshops would you be interested in? (check all that apply):

Stress ManagementStudy SkillsTax PrepFAFSA AssistanceCareer ReadinessResume & Cover Letter WritingFinancial Literacy (debt, budgeting, credit, house buying, etc.)Transferring to a 4-year InstitutionCollege SuccessCommunication Strategies
What might keep you from completing your degree? (family, social life, money, work, etc.): *
RELEASE OF INFORMATION:
By signing this form, I authorize the TRIO SSS staff to obtain all information and documentation necessary for the ongoing evaluation of my academic pursuits, including the information on file at WNCC, as required by the United States Department of Education. Furthermore, I agree to allow the SSS Program staff to release information to colleges to which I have applied for a transfer and to allow colleges to which I transfer to release information to the SSS program for tracking purposes. I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that information on this application and in my TRIO SSS paper and electronic files may be provided to WNCC personnel as needed.
PARTICIPATION AGREEMENT:
By signing below, I agree to actively participate in the TRIO Student Support Service Program to support my work toward my academic, career, and professional goals by regularly receiving advising & other services (coaching, tutoring, workshops, etc.). An active participant is a student enrolled at WNCC with a minimum of 6 credit hours and has met with the SSS professional staff at least twice per academic year.

I have read and understand my responsibilities as a TRIO SSS Program participant. I understand that the services and benefits of TRIO SSS are available to me based on my active program participation.
Student Name

First NameLast Name
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
TRIO Student Support Services is funded by the U.S. Department of Education
A COPY OF THIS APPLICATION IS AS VALID AS THE ORIGINAL
Western Nebraska Community College • 1601 E. 27th St. Scottsbluff, NE 69361 • (308) 635-6190 • trio.team@wncc.edu

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Western Nebraska Community College TRIO Student Support Services Application

PERSONAL INFORMATION:

EDUCATIONAL HISTORY & OCCUPATIONAL GOALS:

ADDITIONAL INFORMATION:

ELIGIBILITY FOR SERVICES:

SKILL/NEED SELF-ASSESSMENT:

RELEASE OF INFORMATION:

PARTICIPATION AGREEMENT: