TRIO Student Support Services Application
Name:
*
First Name
Middle Name
Last Name
Preferred Name
First Name
Middle Name
Last Name
Student ID
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
mm-dd-yyyy
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Personal Email
*
example@example.com
Preferred Contact Method
Text
Call
E-Mail
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Gender Pronouns (Optional)
Ethnicity
Hispanic
Black or African American
American Indian/ Alaskan Native
White
Asian
Native Hawaiian or Pacific Islander
Decline to state
Other
Physical or Learning Disability
Physical or Learning Disability (Optional Disclosure)
Yes
No
Disability Status (Optional)
Active DSPS Participant
Yes
No
Have DSPS Accommodation
Yes
No
Semesters Enrolled in DSPS:
Main Campus Information
Main Campus Information
Coalinga College
Lemoore College
Firebaugh Center
How Many Units Enrolled In?
Full Time 12+ Units
Part Time 6+ Units
Less Than 6 Units
Not Currently Enrolled
Enrolled In College Courses During High School
Yes
No
High School Attended
Received High School Diploma/GED
Yes
No
Declared Major
Transferring from
Transferring from Other College
Yes
No
Plan to Transfer to 4 year Institution
Yes
No
Received AA/AS Or Certificate
Yes
No
Transferring to:
Financial Information
Have you submitted your FAFSA or CADAA?
Yes – FAFSA
Yes – CADAA
No – FAFSA
No – CADAA
Did either one of your parents/guardians receive a Bachelors Degree in the U.S?
Yes
No
House Hold Size
Expected House Hold Income
First Generation Student
Yes
No
Low Income Student
Yes
No
Are you a Foster Care Youth
Yes
No
Student Aid Index (EFC)
Are you an individual who lacks a fixed, regular, and adequate nighttime residence
Yes
No
Academic Need/Obstacle Information
Academic Need/Obstacle Information
Lack of Educational or Career Goals
Lack of preparedness for college level work
Out of academic pipeline for 5 or more years
Low GPA
Limited English Proficiency
Academic support to raise grades in academic major
Failing grades
Active Participant in the following programs(Check all that apply)
EOPS
MESA
CAMP
CalWORKS
CARE
PUENTE
Athlete
HEP
DREAM
Please state why you are applying for TRIO SSS and what types of assistance you desire or think you will need.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
mm-dd-yyyy
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