Jefferson College District Of Jefferson County-SSS-2025 Application Form

Services for all Project SUCCESS participants are completely free!
This application won’t take too long, and it’s an amazing program.
APPLICATION
Applicants who are granted eligibility must meet criteria proving an academic need for our services. You must be seeking a transferable AA degree with intent to obtain a bachelors. Most AAS certificate programs do not qualify. Aside from intending to transfer, you need to meet at least ONE eligibility criteria: First Generation, have any Disability, or meet Low Income guidelines. All information will be strictly confidential. To determine eligibility, please compete all sections of this application.
PERSONAL DATA
Name*

First NameMILast Name
Student ID#:*
V00XXXXXX
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
(999)999-9999
Other/Additional Phone:
(999)999-9999
Do we have your permission to send you text messages?

YesNo
Jeffco Email Address:*
example@example.com
Personal/Individual Email Address:
example@example.com
Gender: Required only for reporting purposes to the U.S. Department of Education

MaleFemaleNon-BinaryPrefer to self-describe:
U.S. Citizen:

YesNo
Please be aware that per U.S. Department of Education regulations, Project SUCCESS is allowed to only work with students who have full U.S. Citizenship. If you are not a citizen, this program may not be right for you, but for further assistance feel free to contact Jefferson College's Coordinator of International & Veteran Services at tthoma15@jeffco.edu.
Veteran:

YesNo
Ever in the Foster system?

YesNo
Currently without a permanent residence?

YesNo
Primary language spoken:
Ethnicity: Are you Hispanic/Latino

YesNo
Race (please check all that apply):

American Indian/Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian/Other Pacific IslanderOther
ELIGIBILITY:

To be considered for program participation, you must be enrolled in Jefferson College, be a U.S. citizen, and committed to achieving an Associate of Arts degree at Jeffco with intent to complete a bachelors at a 4-year institution. In addition, participants must meet AT LEAST ONE of the following: income eligible; be a first-generation college student; or have a documented disability.
First Generation Status: Did either of your parents/adoptive parents obtain a four-year (Bachelor’s) degree?

YesNo
Disability/Accessibility Information: Do you wish to disclose that you have a documented physical or learning disability?

YesNo
If yes, is documentation for the disability on file with Jefferson College’s Accessibility Resource Office (ARO)?

YesNo
Income Eligibility

I am able to provide income eligibility/tax information nowI would like to complete the income eligibility/tax information at a later time and continue working on the rest of this form
First, you will need to determine if you are considered an independent or dependent student by considering the following questions:
- Have you been determined to be an independent student by the Jefferson College Financial Aid Office?
- Are you currently 24 years of age or older?
- Are you married or separated (not divorced)?
- Do you have children or other dependents (aside from a spouse) who lives with you and they receive more than half of their support from you?
- Since you turned 13, were you ever an orphan, in foster care, or a ward of the court?
- Are you, or were you, a legally emancipated minor?
- Do you or did you have a legal guardian other than a parent or step-parent?
- Are you a veteran who was on active duty and released under a condition other than dishonorable?
- Are you currently serving on active duty in the U.S. Armed Forces (other than training)?
If you answered “No” to all of the above questions, you are considered a Dependent student.
You may qualify for Project SUCCESS in other ways, such as being a First Generation Student or by having a documented disability, but in order to be considered for low-income program eligibility, you MUST complete your taxable income information prior to being allowed into the program. This may be completed in our office, but you will need to have your previous year's tax information available.
What is your dependency status?*

DependentIndependent
If Dependent - students will need their parent or legal guardian to complete the information below using their most recent income tax return (IRS Form 1040).
How many people are in your family?*
Did you file a federal income tax return last year?*

YesNo
If you filed, what was your taxable income? (IRS Form 1040, Line 15)*
Signature of Parent / Legal Guardian*

Clear
If Independent - students complete information using their most recent income tax return (IRS Form 1040).
How many people are in your family, including yourself?*
Did you file an income tax return last year?*

YesNo
If you filed, what is your taxable income? (IRS Form 1040, line 15)*
Student Signature*

Clear
EDUCATIONAL DATA:
High School attended:
Year High School diploma or GED/HiSet was earned:
Do you plan to graduate from Jefferson College with a degree and then transfer to a 4-year college to earn your bachelors?

YesNo
Do you plan to transfer to another college before fully obtaining your degree from Jefferson College?

YesNo
College Major/Field of Study:
Highest level of education you would like to pursue:

CertificateAAS DegreeAssociate’s DegreeBachelor’s DegreeMaster’s DegreePhD.
CONCERNS: Check all items that are of concern to you:

Uncertain academic/career goalsTransportation problemsWork demands that conflict with academic goalsLack of money to meet educational, living, and personal needsFamily issues interfering with academic achievementSucceeding in classesDisability concernsOther
SERVICES Check any services that you are interested in:

Academic advisingAcademic supportCultural eventsDisability supportFinancial aid assistanceInformational workshopsLeadership developmentPersonal supportTransfer assistanceTutoring
HOW DID YOU HEAR ABOUT US?

Classroom visitCOL101 classViking Ready Orientation (VRO)Friend or family memberProject SUCCESS staffProject SUCCESS participantOther College employeeOther
PREFERRED APPOINTMENT METHOD?

In-person meetingVirtual meetingPhone meeting
AGREEMENT:

I understand the SSS Program will use the data provided on this form to assist in assessing any academic and/or career planning needs and all information will be kept confidential according to FERPA laws. I hereby authorize the release of appropriate educational, financial aid, income, personal, disability documentation and other information as deemed necessary by the Director of Student Support Services for official use at Jefferson College. I certify the information on this application is true and accurate to the best of my knowledge.

I understand that Project SUCCESS reserves the right to admit or deny any student enrollment in the TRIO SSS program. Application completion does not guarantee acceptance into the program. I understand that if accepted I will be required to attend at least one orientation and meet with my Coordinator within the first 30 days.
Opt-in/opt-out of signing electronically*

Sign electronicallyManually in the office
Print (full name):*

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
TRIO Student Support Services/Project SUCCESS is 100% federally funded by the
U.S. Department of Education in the annual amount of $318,277.
Phone: 636-481-3281 • www.jeffco.edu/projectsuccess
1000 Viking Drive • Student Center Rm 217 • Hillsboro, MO 63050
It is the policy of Jefferson College that no person shall, on the basis of age, ancestry, color, creed, disability, genetic information, marital status, national origin, race, religion, sex, sexual orientation, or veteran status, be subject to discrimination in employment or in admission to any educational program or activity.
Note: If accommodations for a disability are needed contact the
Accessibility Resource Office – ASII Room 303, (636) 481-3158 or email: aro@jeffco.edu. TTY users dial 711.

APPLICATION

PERSONAL DATA

EDUCATIONAL DATA: