Manchester Community College-SSS-Application Form

Please complete all parts of this application to be considered for admission to the STARS program at CT State Manchester. This form can only be filled out by being logged into your CT State Manchester email. You can only submit this form once.

Eligible students must meet at least ONE of the following qualifiers, AND display evidence of academic need.

First Generation College student (neither parent earned a bachelors degree)
Income eligible (SAI = -1500, or, family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount: https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html)
Documented disability (On file with CT State Manchester Office of Disability and Accessibility Services)

2025 STARS Summer Program Application: Available Spring 2025

Contact us!
Theresa Legein, 860-512-3304, theresa.legein@ctstate.edu
Leo Jones, 860-512-3306, leo.jones@ctstate.edu
Jen Blais, 860-512-3307, jennifer.blais@ctstate.edu

Office: SSC L231 (Second floor Student Services Center, past Culinary Arts Center)

Our Website: http://manchestercc.edu/STARS
Our Instagram: @ctstatemcc_triostars

Note: TRIO Student Support Services/"STARS" is a U.S. Department of Education federally-funded program.

This form will record your name, please fill your name.

1. Full Name*

First NameLast Name

2. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3. Cell Phone*

(999)999-9999

4. CT State Outlook email address *

firstname.lastname@ctstate.edu

We will primarily contact you through your CT State email, as well as through our text messaging platform "Remind.”

5. Personal email address

example@example.com

6. Date of Birth*

mm-dd-yyyy

7. Banner/Student ID Number *

8. Gender*

ManWomanNon-binary or another genderPrefer not to say

9. Pronouns

10. Place of Birth

11. Marital Status

SingleMarriedDivorced

12. Are you a US Citizen?*

YesNo

13. Are you a permanent resident?*

YesNo

14. Are you a veteran?

YesNo

15. Are you employed?

YesNo

16. If yes, how many hours per week?

17. What is your ethnic background (Select one or more)

18. Number of people in your family

19. Does your family receive AFDC (Aid to Families with Dependent Children) or other state assistance?

YesNo

20. Do either of your parents or legal guardian hold a bachelor's degree?*

YesNo

21. What is/was your family's attitude toward your attending college? (select one)

Discouraged youLeft the decision to youEncouraged/expected you to goInsisted that you go

22. Is English your native language?

YesNo

23. If no, what is your native language?

24. Do your parents or guardians speak a language other than English at home?

YesNo

25. If yes, what other language(s) is spoken at home?

26. Are you receiving financial aid from Manchester Community College?*

YesNo

27. If yes, please list the amount of financial aid that you received for the school year that you are completing this application in (fall - summer).

Please upload at least one of the following:
1) An unredacted copy of your ISIR (Institutional Student Information Record) from your most recent FAFSA application. This is the report generated when you complete and submit the FAFSA. Contact us if you need assistance finding the ISIR.
2) Parent/Guardian's most recent Federal Income Tax Return/W2 form. If you are an independent student, upload your own tax return documents.

As a federally funded TRiO program, we are required to provide documentation of a student's eligibility for the program to the U.S. Department of Education and implement the TRiO regulations that state two-thirds of the students served must meet federal low-income guidelines. Please check below if you are an independent or dependent student according to the 2022 tax year.

Independent student (typically age 24 or older by December 31 of this year, married or emancipated; parental income is not reported on the FAFSA)Dependent student (younger than 24, unmarried or not emancipated; parental income is reported on the FAFSA) Parent/guardians must complete the next section.

Independent Students and Parents of Dependent Students - What were your total number of exemptions (total number of people in household) in 2022?

Independent Students and Parents of Dependent Students - What was your or taxable or total income in 2022?

Did you, the independent student, or parent of dependent student, not file taxes because your income was less than was required to file?

YesNo

Independent Students and Parents of Dependent Students – Type your name and today’s date to certify that the information entered for questions 29-31 is correct to the best of your knowledge.

Alternatively, to answering questions 28-32, you may upload a copy of any of the following documents:

- Tax documents from 2022 (1040, 1040-SR, Schedule A)

- Proof that you or your family receive assistance from government programs like SNAP, WIC, Welfare, Free or Reduced Lunch, AFDC. Etc.

File Upload

28. Do you have a documented disability?*

YesNo

29. If yes, have you submitted documentation to the Office of Disability and Accessibility Services at CT State Manchester? Participants may only be accepted on the basis of disability if documentation has been provided to ODAS.*

31. What is your English Placement? (ENG 0960, 0930, 1010/0910, 1010) (ESOL 0902, 1202, 1302, 1402 etc) OR enter your High School GPA

32. What is your math placement? (Math 0988. 0989, 1000 - 1012, 0901 - 1201, 1100 - 1201) OR enter your High School GPA and/or ALEKS PPL score

33. Do you have a high school diploma?

YesNoPending

34. Name of high school / graduation year

35. Have you passed the high school equivalency exam GED?

YesNoPending

36. If you earned a GED, what town/state did you earn it and what year did you graduate?

37. Are you a home school graduate?

YesNoPending

38. If yes, what town were you home schooled and what was your graduation year?

39. Academic Need: Please answer the following questions to assist us in determining your academic need. There is no right or wrong answer! Your honesty is important in providing you with the best possible services*

	Yes	No
Is it difficult for you to take notes in classes?
Do you have a hard time understanding what you read?
Is preparing for and/or studying for tests a challenge?
Is it difficult for you to remember/memorize information?
Do you feel that your writing skills could use improvement?
Is mathematics a difficult subject for you?
Could your computer skills be improved?
Is it difficult for you to manage your time?
Do you feel anxiety when taking tests?
Do you frequently feel stressed when in a school environment?
Do you feel that your native spoken language may interfere with your ability to succeed in a university environment?
Have you been out of school for five or more years?
Are you unsure of your educational goals?
Are you unsure of your career goals?

40. How did you hear about our program?

41. What would you like to gain from participating in TRIO Student Support Services/STARS?

42. By signing this document, I certify that my answers are true and complete to the best of my knowledge.*

43. Please read each statement below and provide your digital signature to confirm that you understand and agree

TRIO grants require the submission of an Annual Performance Report (APR) from each program yearly. To create this report, we use a TRIO specific software called Blumen Online for TRIO. To help us develop this report, we collect and enter Academic, Demographic, and Financial data into that software. Data is entered once upon entry into the program, and then again every year before submitting the APR. Your consent to us entering this data will help us to better our services. Blumen Online for TRIO is backed by Microsoft's SQL Server 2012, your data is secure and tunneled via leading SSL technology with 256 bit encryption. Their website is Verisign certified for Encrypted Data Transmission and your data is protected from malicious attacks with additional hardware and software firewalls, ensuring peace of mind when accessing sensitive information.

How long will my data be stored? (eCFR 200.334 Retention requirements for records)

Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. After this three year period, paper records are shredded and digital data deleted.

- I hereby give my permission for the CT State Manchester TRIO Student Support Services (STARS) staff to access my academic and financial aid records and to verify my registration with the Office of Disability and Accessibility Services if 'yes' was answered to that question. This verification helps ensure that my accommodations are set appropriately.

- I hereby give permission for the CT State Manchester TRIO SSS staff to collect and enter records of my demographic information (name, address, phone number, email, date of birth, student ID number, gender, ethnicity, 1st generation status), academic information (college grade level, enrollment status, academic standing, GPA, transfer status, degree completion status), financial information (amount of financial aid received - acquired from professionals in the office of Financial Aid) and other data as needed or required by the CT State Manchester TRIO program into Blumen Online for TRIO (BOT).

- I hereby give my permission for the CT State Manchester TRIO SSS staff to access my midterm and semester grades electronically for the purpose of supporting me and my academic performance at CT State Manchester. I understand that I will have access to my academic record at any time via established college procedures in the Registrar’s Office.

- I hereby give my permission for the CT State Manchester TRIO SSS Program to photograph me at events and use my name and photograph, in the promotion of the program.

- I hereby give my permission for the CT State Manchester TRIO SSS Program to message me through the Remind Application

- Yes, I want to be a member of the CT State Manchester TRIO Student Support Services Program.

Signature

44. If you are under the age of 18, please have a parent type their name (acknowledging this as an official signature) to verify the information provided in this application

Eligibility Application for STARS (TRIO Student Support Services)