Columbia State Community College-SSS-Application Form

Columbia State Community CollegeTRiO Student Support Services Application
Name*

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
(999)999-9999
Secondary Phone
(999)999-9999
School Email*
example@example.com
BANNER ID Number*
Gender

MaleFemale
Birth Date

MonthDayYear
Date

ETHNIC GROUP
Please select all that apply

Caucasian/ WhiteAfrican-American/BlackHispanic or LatinoAsian/Pacific IslanderNative AmericanOther
Native American: Tribe

CITIZENSHIP
Are you a U.S. citizen

YesNo
If “No”, are you an eligible non-citizen?

YesNo
Alien Registration Number:

EDUCATIONAL INFORMATION
Are you planning to obtain a degree or certificate at Columbia State?

DegreeCertificate
What is your major?
How many hours are you planning on attending

Full Time (12 hrs.)3/4 Time (9 hrs.)Part Time (6 hrs)
How were you referred to TRiO Student Support Services?

ELIGIBILITY AND VERIFICATION : completed by student
First-Generation Verification - The term “first generation college student” means
1. An individual both of whose parents did not complete a baccalaureate (bachelor’s or 4-year college) degree, or
2. In the case of any individual who regularly resided with and received support from only one parent, an individual
whose only such parent did not complete a baccalaureate (bachelor’s or 4-year college) degree.

Highest educational level or grade your father and your mother completed.

	Mother	Father
Elementary School
High School
College (less than four years)
College (Bachelor's Degree or higher)

Did you reside with your;

MotherFatherBoth
Under the above definition, Are you a “First Generation College Student.”

YesNo
I verify that the above is true and that neither of my parents completed a baccalaureate degree and I am a “First Generation College Student.”
Student Signature

Clear
Date

MonthDayYear
Date

DISABILITIES VERIFICATION
Do you have any documented physical and/or learning disabilities?

YesNo
If yes, is the disability information on file with the Columbia State Community College Disability Office.

YesNo

INCOME VERIFICATION: To be completed by parent or guardian.
Please indicate family/household annual Taxable Income from your most recent tax return. Taxable Income is found on Line 43 on a 1040 return and Line 27 on a 1040A return.
Number in household claimed on your last year IRS Income Tax Form (including yourself)
Number in household claimed on your last year IRS Income Tax Form (including yourself)
Adults
Children
Other
Documentation of Low Income Eligibility (need at least one):

Copy of your last year’s Income Tax Form. If you did not file federal income taxes, provide income verification from an appropropriate government source.Verification of Financial Aid award letter if you receive a Pell Grant (our office can request this for you).Self-signed statement of low-income verified through TRiO staff using federal guidelines
File Upload

Cancelof
I (parent or guardian), certify that my taxable income for the previous year was below the qualifying income levels (Income Chart).

Clear

PARTICIPANT AGREEMENT & RELEASE OF INFORMATION
As a participant in the Columbia State Community College TRiO Student Support Services Program, I am committed to my education. To gain the full benefits of the program, I will make a commitment to my academic goals and the assistance provided. I also understand the TRiO Student Support Services staff will review data from my application and interviews to assist in assessing my academic and career planning needs. Therefore, all information used will be kept strictly at the highest level of confidentiality. I give the TRiO Student Support Services Program staff permission to inquire about my class attendance, class work, and tutoring sessions and receive grade reports; and I give my instructors permission to release such information to TRiO Student Support Services staff when requested. Should I not meet the requirements and fulfill my academic goals, it may result in serious consequences regarding my continuation as a participant in the TRiO Student Support Services Program.

I authorize the TRiO Student Support Services Program staff to gather information concerning all my academic progress (standardized test scores, grade point average, earned credit, transcripts, tutoring, etc.) and financial aid status prior to my participation in the program. I also grant permission to the ADA Office to release information to TRiO Student Support Services if I fall under the disability
status. I understand that this information is used to help determine my eligibility for the program and will be kept strictly confidential. I grant permission for the TRiO Student Support Services Program to gather information for follow-up whenever appropriate, including, but not limited to, transfer and progress to four-year institutions. I am aware that my eligibility and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations. I certify that the information provided on this application is true and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information reported.

I also hereby authorize the use of my photographic image in any and all publications, such as the monthly newsletter, newspaper articles, and campus-wide e-mail notices. I authorize Columbia State Community College to use my name, photo, or information about me in promotion of the college through radio, television, or other printed materials. I understand that my picture could come from a digital image such as my file or from photos taken on various field trips and social events. I am aware that personal information provided to the TRiO Student Support Services Program will be protected under the Federal Education Rights & Privacy Act (FERPA) of 1974. No one will have access to the information unless they work with or for Columbia State Community College and TRiO Student Support Services Program.

AFFIDAVIT OF TRUTH STATEMENT
The information provided on this form is, to the best of my knowledge, accurate and true.
Student Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature

Clear
if under 18 parent signature is required
Date

MonthDayYear
Date

Columbia State Community CollegeTRiO Student Support Services Application