Wilson Community College-SSS-Application Form

NEW STUDENT APPLICATION
Dear Student Support Services Applicants:

TRiO Student Support Services (SSS) provides eligible participants with the support they need to successfully complete their program of study or assist them with transferring to a four-year college or university. The following services are available to participants:
- Coaching and Mentoring
- Financial Aid and Literacy advising
- College Campus Tours
- Book Clubs
- Workshops
- Academic Tutoring
- Cultural enrichment opportunities
- College Transfer assistance and so much more!
To be considered for participation in Student Support Services at Wilson Community College, please complete this application in its entirety. The application can be saved and resumed if necessary before submission. Participant eligibility is determined by academic need, income, first generation or disability status, and commitment to participate in the program. If you have further questions regarding accessing/submitting the Student Support Services application, please contact TRiO Programs at (252) 246-1256 or via e-mail at trio@wilsoncc.edu. Physical copies are available upon request. Thank you for your interest in Student Support Services.

TRIO WORKS!
PERSONAL DATA
WCC Student ID:
1. Name:*

First NameMiddle InitialLast Name
2. Birthdate*

MonthDayYear
mm-dd-yyyy
3. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Primary Phone Number:
(999)999-9999
Alt Phone Number 2:
(999)999-9999
5. WCC E-mail:*
example@my.wilsoncc.edu
Alternate E-mail:
example@example.com
6. Parent/Guardian Name (if under 18):

First NameLast Name
7. Ethnicity:

American Indian or Alaskan NativeAsianBlackHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOther
8. Citizenship:*

U.S. CitizenResident AlienNon-resident AlienPending Citizenship
9. Gender assigned at birth:

MaleFemale
10. Preferred Pronouns:

She/HerHe/HimThey/ThemZe/Zie
11. Marital Status:

SingleMarriedSingle ParentDivorced
ACADEMIC INFORMATION
12. Curriculum Program of Study:
13. First enrollment at WCC (ex. Fall 2015):
14. Current Cumulative GPA:
15. Current classification:

1st Time FR (0-29 hrs)2nd Time FR (1-29 hrs)SO (30-59 hrs)
16. Current Enrollment Status:*

FT (12+ hrs)¾ Time (9-11 hrs)½ Time (6-8 hrs)Less than ½ Time (< 6 hrs)
ELIGIBILITY INFORMATION
17. Parent(s)/Guardian(s) occupation: Father:
Parent(s)/Guardian(s) occupation: Mother:
18. Do either of your parents have a Bachelor’s (4-year) college degree?*

YesNo
19. Do you have any documented disabilities?

YesNoPrefer not to answer
20. If yes, are you registered with Accessibility Services on campus?*

YesNoPrefer not to answer
EDUCATIONAL BACKGROUND
21. High School Attended/GED:
22. Graduation Date:

MonthDayYear
mm-dd-yyyy
23. Are you an Early College student (WECA or WAAT)?*

YesNo
24. Grade Level

910111213
25. High School GPA:
26. Have you taken:

SATACT
27. Have you attended another college?

YesNo
28. If “yes,” where and when:
29. Have you ever been a member of Student Support Services at any other college you attended?

YesNo
30. Have you received a degree, certificate, or diploma from WCC or another community college?*

YesNo
31. If “yes,” where, when, and what program?
FINANCIAL AID INFORMATION
32. Have you applied for financial aid?*

YesNo
33. Do you receive Federal Pell Grant?*

YesNo
34. Are you currently on financial aid warning, probation, or suspension?

YesNo
35. Are you a veteran?

YesNo
INCOME AND DEPENDENCY INFORMATION
36. Check the statement below that applies to you:*

I am a DEPENDENT student. (Dependent students are younger than 24, single, are not in foster care or a ward of the state, are not active duty or a veteran. Dependent students use their parents’ financial information on the FAFSA.)I am an INDEPENDENT student. (Independent students may be 24 or older, married or emancipated, have children, are in foster care or award of the state, are active duty or veteran. Independent students do not use their parents’ financial information on the FAFSA.)
37. How many people are living in your household?*
To determine your household size, include yourself, spouse (if married), number of children under age 24, and the number of people who live with you and receive more than half of their support from you (or guardians if dependent).
38. What was the Actual Taxable Income for the most recent tax year? $*
(For self/spouse if INDEPENDENT or for parent/guardians if DEPENDENT. Located on the 1040 Tax return, Line 15. Do not list adjusted gross income or wages earned).

NEEDS ASSESSMENT

	Yes	No
39. I need to make better grades in my courses.
40. I am enrolled in Transition English and/or Transition Math (002/003)
41. I need tutoring.
42. I need to learn how to set goals and make better decisions.
43. I need to develop stronger study skills and habits.
44. I need to better understand my interests, abilities, and other traits.
45. I need to learn about the correct academic courses for my program.
46. I do not feel academically prepared for college level coursework.
47. I have difficulty reading, speaking, writing or understanding English.
48. I have thought about dropping out of college.
49. I need assistance with financial aid and researching scholarships.
50. I have been out of the academic pipeline for 5 years or more.
51. I plan to transfer from WCC to a 4-year college/university.

Tutoring Subjects:
AUTHORIZATION FOR RELEASE OF INFORMATION
I understand that all information that is requested is required and will be obtained and handled confidentially by program staff for Federal reporting purposes. I hereby grant permission to Student Support Services to obtain requested information from my personal file and student records (including enrollment, attendance, grades, financial aid, disability documentation, and student employment) for the purpose of helping me to succeed while enrolled at Wilson Community College.

I hereby certify that the information given on this application is true and correct to the best of my knowledge. I agree to participate in all program activities (tutoring, advising, workshops, field trips, and study labs).
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
(If student is under 18 years of age)
Date

MonthDayYear
mm-dd-yyyy

NEW STUDENT APPLICATION

PERSONAL DATA

ACADEMIC INFORMATION

ELIGIBILITY INFORMATION

EDUCATIONAL BACKGROUND

FINANCIAL AID INFORMATION

INCOME AND DEPENDENCY INFORMATION

AUTHORIZATION FOR RELEASE OF INFORMATION