California State University-Fresno-Disabled-SSS-Application Form

TRIO Student Support Services – Disabilities (SSS-D) Application
TRIO Student Support Services - Disabilities (SSS-D) is a U.S. Department of Education federally funded program that serves undergraduate college students with a demonstrated academic need.

You may be eligible to receive TRIO SSS-D program services if you are actively receiving accommodations through Services for Students with Disabilities (SSD) on campus and identify as one or more of the following:
• A first-generation college student.
• A low-income college student.

Undergraduate Degree Information
Major:*
Minor:
Expected Graduation Date:*
Current Class Level*

Freshman (0-29 units)Sophomore (30-59 units)Junior (60-89 units)Senior (90+)

Financial Aid Information
Check All That Apply to You:*

I am Eligible for Federal Financial Aid.I am Not eligible for Federal Financial Aid.I Completed the Free Application for Federal Student Aid (FAFSA).I did not apply for Federal Financial Aid.I plan to submit my Free Application for Federal Student Aid (FAFSA)

Family Income Status
When filing income taxes, do you consider yourself an Independent or Dependent Student? (Select one):*

Independent Student – a student is considered independent if they are 24 years or older, married, a veteran, is/was a foster child or a ward of the court, or has a child that is under 18 years old and is financially dependent on them (Must meet at least one of the above criteria). Please submit your and your spouse's (if applicable) most recent 1040 Income Tax Return.Dependent Student – A student is considered dependent if they are under 24 years old and do not meet any of the criteria to be considered an independent student. Please submit your and/or your parents/legal guardians' most recent 1040 Income Tax Return.
Household Size (including yourself):*

Photo Release
If accepted, I grant permission to TRIO Student Support Services – Disabilities (SSS-D), on behalf of California State University, Fresno State, and its agents or employees, to use photographs taken of me for use in university publications such as recruiting brochures, newsletters, newsprint, and magazines, and to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on University web sites or other electronic forms or media, and to offer them for use or distribution in other non-university publications, electronic or otherwise, without notifying me.

I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or
other compensation arising from or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless TRIO SSS-D on behalf of California State University, Fresno, and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I am 18 years of age or older, and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
What to use*

Use Both Name & Photo.Use Neither Name & Photo.
Signature:*

Clear
Date:*

MonthDayYear
Date

Confidential Policy and Release of Information
Information provided to the TRIO Student Support Services – Disabilities (SSS-D) Program regarding a student’s academic work is considered confidential. No information about a student is released to any on/off campus individual/agency without the student’s written consent.

To work effectively with students, TRIO SSS-D may need to share information with and/or obtain information from other Fresno State departments, instructors, and other professionals who have a legitimate educational need to know. When it is necessary and appropriate to discuss your educational situation with other Fresno State employees and off-campus agency individuals, they will be reminded of their obligation to keep this information confidential as mandated by FERPA (Federal Family Educational Rights and Privacy Act of 1974). This may include but is not limited to: Accessibility Services, Student Health and Counseling Services, Academic Advising and Career Education, WorkAbility IV Program, and California Department of Rehabilitation. Only information that TRIO SSS-D deems appropriate is released, and only for the following reasons:

• To assess a student’s need for TRIO SSS-D services.
• To advocate (when requested) on a student’s behalf
requirements.
• To provide appropriate TRIO SSS-D services.
• To comply with University/CSU and TRIO SSS-D reporting.

If accepted, I understand that I have a right to receive a copy of this authorization upon my request. I authorize TRIO SSS-D to share information about me under the conditions outlined above. I understand that this authorization becomes effective immediately. It shall automatically terminate upon graduation from Fresno State or when I am no longer registered at Fresno State. A photocopy of this form is as valid as the original.
Signature:*

Clear
Date:*

MonthDayYear
Date

Required Supporting Documentation
Program participation is contingent upon submitting one of the following appropriate documents:
Proof of income form:
- Income Tax Return: Please refer to “Family Income Status” above to see what
  you will need to submit. Documentation can be obtained by logging into/creating a IRS Individual Online Account. (hyperlink: https://www.irs.gov/payments/online-account-for-individuals)
- If taxes were not filed, please submit the most recent W-2s from the appropriate individual(s) along with an IRS Verification of Non-Filing Letter.
Documents can be submitted via email or in person after submission of this digital application. Your application will be reviewed when all appropriate documents are submitted. If you have any questions regarding these documents please email
trio_sssd@mail.fresnostate.edu.
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TRIO SSS-D Participant Agreement
If accepted as a TRIO SSS-D program participant, I understand that each semester, I am required to complete participant requirements. I understand my participant requirements depend on my class level, as shown on the TRIO SSS-D Webpage: Student Responsibilities.

I certify that all the information provided in this application is accurate and complete to the best of my knowledge. If requested, I agree to provide further documentation to verify the information reported.
Signature: *

Clear
Date:*

MonthDayYear
Date

TRIO Student Support Services – Disabilities (SSS-D) Application