Palm Beach State College-Veterans-SSS-Application Form

Student Support Services,Veterans
Date:

MonthDayYear
mm-dd-yyyy
DOB:

MonthDayYear
mm-dd-yyyy
Gender:

MaleFemale
Applicant's Name:*

First NameMiddle InitialLast Name
PBSC SID#:*
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone
(999)999-9999
Cell phone*
(999)999-9999
PBSC Email Address:*
example@example.com
Personal Email:
example@example.com
How did you learn/hear about Student Support Services,Veterans TRiO?
Have you participated in TRiO before?

YesNo
If yes, when and which program.
Campus Location:

Belle GladeBoca RatonLake WorthLoxahatchee GrovesPalm Beach Gardens
I am registered for classes at PBSC.

YesNo
My attendance will be mostly:

Full-timePart-TimeOnline
What is the primary language spoken at home?
Other languages spoken:
Did you earn your high school diploma?

YesNo
Date of GED

MonthDayYear
mm-dd-yyyy
What degree are you seeking?

AAASCCP/Certificate
Major:
To what college/university do you plan to transfer?
To what college/university do you plan to transfer? Select if applicable:

Unsure Don’t intend to transfer
Have you attended college before?

YesNo
If yes, where and how many credits have you earned?

Previous colleges:

	Institution	Number of Credits	Type of Degree Earned
1
2

Tell us about your academic and career goals:
Are you a US Citizen?

YesNo
If no, are you a permanent resident?

YesNo
(Please provide proof)

Cancelof
Do you identify yourself as Hispanic/Latino?

YesNo
Please select the race(s) with which you identify: (Check all that apply)

WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian or other Pacific Islander
If yes,
1. Do you have a documented disability?

YesNo
2. Have you signed up with the College’s Disability Support Services?

YesNo
Have either of your parents graduated from a four-year college or university?

YesNo
If yes, was it your:

MotherFatherBoth Mother and Father
1. Have you applied for financial aid?

YesNoI Plan to Apply
2. Are you receiving financial aid?

YesNoWaiting to HearPell GrantWork StudyLoanScholarshipOtherNone
3. At age 18 were you living with:

ParentBoth ParentsLegal Guardian
4. Are you an independent student?

YesNo
5. Do your parents claim you as an exemption on the tax return?

YesNo
6. Do you have dependents to whom you provide care for 50% or more of the time?

YesNo
Please choose Any area you May have an interest in pursuing:

Veterans ClubKiwanis ClubBoard Game ClubTheater (plays, shows)Free Food (Pantry)Affordable Clothes (Closet)VA AssistanceVeteran Community OrganizationsVolunteer Work
Are you 24 years of age or older?

YesNo
Are you married?

YesNo
Do you have dependent child?

YesNo
Are you a Veteran and/or eligible reservist?

YesNo
Were you a foster child, or are you a ward of the court?

YesNo
I authorize SSSV TRiO to use my name/picture for public recognition as part of the SSSV TRiO program. *
(Initial)
Student Support Services Veterans TRiO is a program designed to help you graduate. The information provided is confidential and will help determine eligibility for the SSSV TRiO program. Discrimination is prohibited on the basis of race, gender, color, national origin, religion, age, disability, marital or parental status, or sexual orientation. I hereby authorize SSSV TRiO to access, obtain, and share any information pertinent to my participation in the program. This information includes, but is not limited to, financial aid information, standardized test scores, transcripts, disability documentation, transfer information, graduation information, and grade reports. Under penalty of perjury, I certify that I have read this application and that it is accurate and complete to the best of my knowledge.
(Applicant’s or Parent/Guardian Signature) *

Clear
(Date)

MonthDayYear
mm-dd-yyyy
SELF-DISCLOSED INCOME VERIFICATION
Name

First NameLast Name
SID
You must complete this form, whether or not you believe you qualify as low.-income.

Verification requirements vary depending on whether you are DEPENDENT or INDEPENDENT, according to federal criteria which is available on the FAFSA website www.fafsa.gov.

Information for the most recent tax year:

I was an Independent Student (typically age 24+, married, emancipated minor, veteran, or parent providing over half of child(ren)’s support). Complete and sign Part A.

OR I was a Dependent Student (younger than 24, unmarried); parent information is reported on FAFSA. Your parent/guardian must complete and sign Part B.
Part A – Independent Student
Total Number of Exemptions*
Or Number of People in Family
Taxable Income
(IRS Form 1040- line 15)
or

I did not file a tax return last year because income was less than required to file.
Student Name – please print. I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge.

First NameLast Name
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Part B – Parent/Guardian Dependent Students Only
Total Number of Exemptions*
Or Number of People in Family
Taxable Income
(IRS Form 1040- line 15)
or

I did not file a tax return last year because income was less than required to file.
Parent/Guardian Name – please print. I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge.

First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
This information will be used only to determine or verify eligibility for the TRIO Student Success Services Veterans program at Palm Beach State College. All information is confidential. The U.S. Department of Education provides more information

I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge.
Contact Information
Name:

First NameLast Name
PBSC SID#:
Phone:
Cell
(999)999-9999
Home
(999)999-9999
Can we leave a message?

YesNo
Text: We may contact you via text message if you have a cell phone number on file with PBSC and have opted in with Palm Beach State College
PBSC Email Address:
example@example.com
Personal Email Address:
example@example.com
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This information is current with Palm Beach State College:

YesNo
I understand that this information is to be used for purposes related to my education at Palm Beach State College and my participation in the Student Support Services,Veterans TRiO program.
Student’s Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
MODEL RELEASE

Please fill out completely and sign at the bottom.
NAME:*

First NameLast Name
STUDENT ID:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE:*
(999)999-9999
E-MAIL (optional):*
example@example.com
Date:*

MonthDayYear
mm-dd-yyyy
I hereby agree that the District Board of Trustees of Palm Beach State College (the “College”), and those acting pursuant to its authority, shall have the right to record my participation, appearance, likeness and voice on videotape, audiotape, photograph, digital, electronic or in any other medium and I hereby unconditionally and irrevocably consent to the College’s use of such materials for any legal purpose the College deems appropriate for the benefit of the College, including commercial and advertising purpose also, I hereby forever waive (i) any right to require payment from the College for use of these materials by it or those acting pursuant to College authority and (ii) the right to object to the use of such materials for any purpose permitted by this Consent and Release, including, without limitation, the license or sale of such materials by the College and those acting pursuant to its authority who publish, print, display, exhibit, distribute or otherwise publicly use any such materials for any legal purposes. I understand the foregoing consent and release grants the College the right to edit, crop, retouch, or otherwise reasonably alter such materials, at its discretion, and, at its option, to reveal my name and identity in such materials or by descriptive text or commentary. Furthermore, I understand and agree that any intellectual property rights associated with such materials are the sole property of the College.
SIGNATURE:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Student Support Services,Veterans Authorization for Release of Information
Student ID:
Name:

First NameLast Name
I, {name109} give my permission to release to the PBSC Student Support Services,Veterans all information pertinent to my educational program including a copy of my midterm grades, degree audit, financial aid application, transcripts, college enrollment status, awards from state and federal funding agencies, post-secondary institutions, and the National Student Clearinghouse. I also give the Student Support Services,Veterans permission to request other documents as necessary to assist me with my admission and enrollment in post-secondary education and financial aid application and awards.
Date of Birth

MonthDayYear
mm-dd-yyyy
Student’s Signature

Clear
Signature of Parent/Guardian if student is a Minor

Clear
Date:

MonthDayYear
mm-dd-yyyy
Program Agreement & Commitment

Student Support Services,Veterans TRiO
Student Name:

First NameLast Name
Student ID#
he achievement of something desired, planned, or attempted is a great feeling. As such, your success at Palm Beach State College and beyond, including your commitment to participate fully in the TRiO Student Support Services, Veterans Program is very important. The TRiO staff is ready to assist you. We ask that you help us in return by keeping us involved.

Summary of SSS/Veteran services available to participants:
- An assigned Advisor to provide you with individual and personalized
  assistance
- Educational, personal and/or career assessment
- Transfer assistance and campus visits to four-year institutions
- Tutorial and academic support
- Workshops and orientation (some mandatory)
- Financial aid assistance, financial literacy, and scholarship resources
- Cultural enrichment events
- On and off campus referral services
In exchange for the Support Services, I agree to abide by the following:

Please read each statement carefully and place your initials in the space provided.
I agree to meet with my TRiO Advisor once monthly during the semester to discuss my academic progress and gain assistance with financial aid/career counseling and/or transfer process.
I agree to inform the TRiO Advisors of any academic difficulties so that I may receive tutoring and other academic services as needed.
I agree to at least attend one cultural enrichment activity, college tour, volunteer event, or any other TRiO sponsored event a year.
I agree to complete financial literacy and attend mandatory workshops as directed by program staff.
I agree to be actively involved in my education. I understand that I am responsible for my own decision making, and the decisions I make affect my education and life goals.
I agree to attend classes regularly and to remain in good academic standing by maintaining a cumulative GPA of 2.0 or above.
I am responsible for checking my email daily for any TRiO information. It is my responsibility to notify the TRiO staff if I’m not receiving any emails from TRiO prior to the end of the semester or if I change my email address.
I agree to follow through on all mandatory requirements and I understand that my failure to comply will result in a TRiO Hold to my student account.
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
New Student Individual Assessment
Name:

First NameLast Name
SID#:
Date:

MonthDayYear
mm-dd-yyyy
I need assistance with: (Please check all that apply)

Scheduling ClassesNote TakingCareer/Major ExplorationGood Study Habits & SkillsUnderstanding Degree RequirementsTest Taking SkillsFAFSA RenewalOrganization SkillsFinancial Aid & ScholarshipsTime ManagementWork Study & Student EmploymentComputer AssistanceScholarship PreparationReading ComprehensionHousing & TransportationAcademic WritingPersonal CounselingMathTransfer Planning & ProcessPeer Mentoring
Academic Needs Assessment

Educational Motivation

	T	F
I know how to take good notes in class
I study on a regular basis
I read my textbooks
I prepare for class ahead of time
I read over my notes after class
I finish assignments on time
I set a goal to do well in college
When a subject is difficult for me I ask for help
I wonder if college is worthwhile for me
It is up to me to do well in college

Academic Concerns

	T	F
I have trouble reading college level textbooks
I have trouble taking notes in class
I would like to improve my grammar/writing
I am uncomfortable asking question in class
I learn best by doing the task
I learn best by listening to explanations
I learn best by watching something being done
I have a fear of reading
I have difficulty concentrating
I know when it is time to ASK for help

Workshops

Time ManagementStudy Habits & SkillsTest TakingTaking Good NotesWriting Research & CitationPersonal EtiquetteBlackboardEntrepreneurshipFinancial Literacy (mandatory)Career Planning & Resume Writing
Student’s Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy

Student Support Services,Veterans

SELF-DISCLOSED INCOME VERIFICATION

Contact Information

MODEL RELEASE

Student Support Services,Veterans Authorization for Release of Information

Program Agreement & Commitment

New Student Individual Assessment