Kellogg Community College-SSS-Application Form

STUDENT SUPPORT SERVICES APPLICATION
PROGRAM YEAR:
According to the U.S. Department of Education, which administers TRIO programming, the Student Support Services program, 100% funded by the U.S. Department of Education: “provides opportunities for academic development, assists students with basic college requirements and serves to motivate students toward the successful completion of their postsecondary education. The SSS program may also provide grants aid to current SSS participants who are receiving Federal Pell Grants. The goal of SSS is to increase the college retention and graduation rates of its participants and to help students make the transition from one level of higher education to the next.” We request students to provide disability information; however, disclosure of any disability is optional.
General Information
Name*

First NameLast Name
KCC ID*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
(999)999-9999
Program of Study*
KCC Email *
example@example.com
Personal Email*
example@example.com
Preferred contact method (Check all that apply)*

Phone callTextKCC emailPersonal emailPostal mail
U.S. Citizen:*

YesNo
Permanent Resident:*

YesNo
Ethnicity:*

Hispanic or LatinoNot Hispanic or Latino
If checked Not Hispanic, please choose Race below:*

American Indian/Alaska NativeAsianBlack/African AmericanWhite/CaucasianNative Hawaiian/Pacific IslanderTwo or more races
Intake Questionnaire

Intake Questionnaire*

	Yes	No
Do you have a documented disability?
Are you currently enrolled at Kellogg Community College?
Are you planning to transfer to a 4-year college/university?
Have you participated in TRIO before (Upward bound or SSS)?
Have you applied for Financial Aid for KCC for the current Academic year?
Do either of your parents have a Bachelor’s degree (4-year degree)?

What services are you interested in receiving?*

Academic AdvisingTutoringFinancial LiteracyCultural EngagementCareer AdvisingScholarship AssistanceTime Management Study SkillsCollege transfer planning/ CollegeCampus visitsOther
Permissions
I. By initialing you are giving KCC's TRIO Student Support Services program and staff
permission to communicate verbally, in writing, via email, or other means to share
information with Kellogg Community College faculty, staff, departments, and/or off
campus professionals.
Initial*
II. By initialing you are giving KCC's TRIO Student Support Services program and staff permission to submit on an annual basis your name and date of birth to the National Student Clearinghouse to verify enrollment and degree information.
Initial*
III. By initialing you are giving KCC's TRIO Student Support Services program and staff permission to obtain, review, discuss, and copy all records and information available through Kellogg Community College, its faculty, departments, staff, including, but not limited to, academic and financial aid records and to release information to the U.S. Department of Education and/or Kellogg Community College faculty, departments, or staff.
Initial*
IV. Initial that you agree that being permitted by the KCC's TRIO Student Support Services Program to participate in the program travel and/or activities, to use its equipment and facilities, you agree to indemnify and hold harmless the Student Support Services program, all Student Support Services, staff, and Kellogg Community College from any and all claims which are in any way connected with such use or participation in student support services program.
Initial*
By signing this form, you certify that all information provided on this application is true.
Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Kellogg Community College TRIO Student Support Services Information Sheet
TRIO Student Support Services (SSS) provides academic advising and personal support to eligible students. Limited financial assistance may be available to qualified participants.

Eligibility

To qualify for TRIO Student Support Services Program, students must be enrolled at Kellogg Community College, exhibit an academic need and one or more of the following:
- First-Generation college student (neither parent has a bachelor’s degree)
- Low-Income (income will be based off the Federal TRIO Programs Current-Year-Low- Income levels)
- Disability (IEP, 504, Doctor’s Note determining a disability)
Available Services
- Financial Literacy, Time Management, and Study Skills Workshops
- Academic Advising
- Tutoring
- Career Advising
- Cultural Events and Trips
- College Transfer assistance
- College Transfer Trips/Tours
- Social Events
Expectations
- Per Semester
  - Meet with the TRIO Program Advisor
- Per Year
  - Attend one Workshop
  - Attend one Social event
  - Attend one Cultural Event
  - Attend at least one College Tour/Trip

STUDENT SUPPORT SERVICES APPLICATION

General Information

Intake Questionnaire

Permissions

Kellogg Community College TRIO Student Support Services Information Sheet