Virginia Western Community College-SSS-Application Form

Virginia Western Community College

SSS-Application Form
Application for Services
Date:

MonthDayYear
mm-dd-yyyy
SSN as a required field:
999-99-9999
Full Name:*

First NameMiddle InitialLast Name
Home Phone #: *
(999)999-9999
Cell Phone #: *
(999)999-9999
VWCC Student E-mail Address: *
example@email.vccs.edu
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Gender:*

FemaleMalePrefer not to sayPrefer to self-describe
Emplid (seven digit student id number):*
Ethnicity

HispanicNon-Hispanic
Race (Check all that apply to you)*

American Indian/Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or other Pacific Islander
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Citizenship:*

U.S. CitizenPermanent Resident (Please provide a copy of your permanent resident card – both sides)Other
Upload copy of your permanent resident card – both sides

Cancelof
Do you speak English as a Second Language?

NoYes, primary language spoken:
What assistance are you seeking?
PROGRAM ELIGIBILITY
Have either of your parents graduated from a four-year college?*

YesNo
Do you have a documented physical, psychological or learning disability?*

YesNo
If yes, are you registered with VWCC Office of Disability Services?*

YesNo
FINANCIAL ELIGIBILITY
Who claimed you for tax purposes the most recent tax year?*

ParentSelfDid not file
Financial Aid Status: (Check all that apply to you)*

Applied & WaitingApprovedNot approvedDid not applyNot eligibleWarning/Suspension
Check agencies which provide services to you and/or assistance you receive:*

Social Security/DisabilityDepartment of Social ServicesSNAP/ TANFVeterans Administration (VA)Children ServicesSection 8Department of Rehabilitation Services (DRS)None of theseOther
For FAFSA purposes, what are you considered? (Typically, students who are less than 24 years of age, unmarried and have no children are considered dependent.)*

DependentIndependent
Number of family members in your household including yourself. Family members are those related to you by blood, marriage, or law.*

123456789 or more
Check the amount below which matches your household’s most recent level of taxable income. For those filing Form 1040, taxable income is found on line 15 for the 2023 tax year.*

$0–$23,475$23,476–$31,725$31,726–$39,975$39,976–$48,225$48,226–$56,475$56,476–$64,725$64,726–$72,975$72,976–$81,225$81,226+
ACADEMIC INFORMATION
Student Classification:*

New Student (no college courses)Continuing Student (some college courses)Second Year Student (at least 30 credits)Transfer Student (transfer credits from another college)Probationary
First semester at VWCC?*

FallSpringSummer
Year:*
Have you ever participated in a TRIO program?*

NoYes- Where?
Anticipated attendance:*

Full Time (12 or more credits)3/4 Time (9–11 credits)1/2 Time (6–8 credits)Less than 1/2 TimeUnsure
Expected Graduation Date:*

FallSpringSummer
Year:*
Are you planning to transfer to a four-year college?*

Yes, AFTER graduating from VWCCYes, BEFORE graduating from VWCCNoUnsure
Major:*
Cumulative GPA:*
OTHER
How did you learn about TRIO: Student Support Services?

VWtvStudentEmail/Student BulletinStaff/FacultyVWCC WebsiteOther
Student:
Staff/Faculty:
If accepted, may we use your name/photo in our newsletter/Canvas/social media for the purpose of recognition, i.e. accomplishments, awards, graduation, transfer, and involvement in cultural activities and/or trips?
Name

Yes, you can use my nameNo, you cannot use my name
Photos

Yes, you can use my photo(s)No, you cannot use my photo(s)
I certify that the information I provided on this application is, to the best of my knowledge, true and accurate. By applying to this program, I authorize TRIO Student Support Services to access information pertinent to my participation from other VWCC departments. Also, I recognize that completing this application does not guarantee my admission to the program.
Parent Signature: (Note: parent signature is not needed if the student over 18 years of age)

Clear
Needs Assessment Survey
Emplid
As a student, I want to: (Check all that apply)*

Improve note taking skillsImprove vocabularyImprove test taking skillsEnhance memoryReceive transfer assistanceImprove math skillsReduce math/test anxietyDevelop a plan for collegeImprove reading comprehensionMake good career decisionsImprove spellingImprove time management skillsImprove grade point averageIncrease college reading speedImprove general study habits
Please check any of the following items which describe you:*

Out of school too longAfraid of failing in collegeDifficulty managing moneyConflict with professorChanged major 1+ timesMay need personal counselingDifficulty meeting deadlinesUnsure of college proceduresAfraid I might not fit in at VWCCDifficulty meeting new peopleDifficulty finding child careWorking too much during weekUnable to understand contentDifficulty participating in discussionsPanic during testsFew computer skillsDifficulty with public speakingNot prepared for course levelRegistered for too many classesDifficulty organizingDifficulty prioritizingLimited experience with Internet
What obstacles would most likely prevent you from completing your academic goals? (Check all that apply)*

Poor study habitsBad gradesFamily medical problemsLack of moneyTake things too seriouslySeparation or divorceTaking the wrong classesAlways feeling tiredTrouble sleepingEasily distractedRecurring health concernsAfraid to speak up in classToo shyAlways worryingNo support from family/friendsDealing with billsTest anxietyAlcohol and/or drug problemsFeeling depressed or sadProblems at homeNo close friends at VWCC
My most important areas which I will need assistance are: (Check all that apply)
Academic:*

Course SelectionSelecting a MajorStudy SkillsTutoring
Career:*

InterviewingResume/Cover LetterJob SearchingCo-op/InternshipLeadership DevelopmentChoosing a Career
Financial:*

Personal BudgetFAFSAGrants/ScholarshipsLoans
Personal:*

Stress ManagementSubstance AbuseRelationshipsAnxietyDepressionMotivationExploring DiversityTime ManagementOrganization/Prioritization
Transfer to a 4-year Institution:*

Search ProcessApplication ProcessFundingPlanningTranscripts

My skills in each of the areas below are: (Check the appropriate box)*

	Excellent	Greater Than Average	Average	Less Than Average	Poor
Math
Science
Reading
Writing

Describe 2 (or more) personal strengths which you feel will help you succeed as a student:*
After graduation from Virginia Western Community College, I plan to:*
Personal Inventory

Directions: Answer each question by marking an “X” under “Yes” if the statement is like you or describes you, or “No” if it is not like you or doesn’t describe you. Answer all questions as honestly as you can with your first impression*

	Yes	No
I want to make changes in my life.
People expect too much of me.
I’m well-liked by people my own age.
Work often upsets me.
I have too many things going on in my life.
My feelings are very important to my family.
At home I lose my temper easily.
I’m very often in a good mood.
I can easily make decisions.
I feel I always have a need to improve myself.
I find it very hard to express my opinions in front of other people.
I’m easy to be with.
I find it hard to get used to new things.
I’d rather give in than fight.
It’s not easy being me sometimes.
My family puts pressure on me.
I’ve often thought of leaving home.
Other people are better looking than I am.
I’d like to feel better about myself.
My family is very supportive of me.

Purpose Statement:

TRIO: Student Support Services is dedicated to working with each accepted student to achieve his/her goals. Student Support Services helps participants to stay in school, maintain good academic standing, and to help them graduate and/or transfer to a four year college.

Who are we?

Student Support Services is funded by the U.S. Department of Education designed to assist low-income, first-generation students graduate from college. TRIO programs began in 1964 with Upward Bound which was created through the Economic Opportunity Act of 1964. Talent Search followed as a part of the Higher Education Act of 1965. The third program, Special Services, currently known as Student Support Services, was authorized in the Higher Education Act of 1968. The name TRIO was then adopted to represent the three programs. In subsequent years, several other programs were added (Upward Bound Math Science, Veterans Upward Bound, and Ronald E. McNair Post-Baccalaureate Achievement Programs) yet the TRIO name has remained. VWCC’s Student Support Services has been on campus since 1975.

Program Expectations

For academic success, program participants are expected to:
- Meet with your Student Support Services Coach at least 3X's per semester
- Attend one cultural enrichment or social program per semester
- Discuss early alerts with your Student Support Services Coach
- Attend all classes, on time, and complete all assignments
- Make a commitment to the program until graduation
- Keep scheduled appointments
- Discuss extenuating circumstances with instructors and let Student Support Services Coaches know if you need assistance
- Seek advising assistance on appropriate courses and course load
- Submit FAFSA by the priority deadline
What services do we provide?

All services are provided at no cost to participants:
- Educational, financial, vocational, & short-term personal counseling
- PRIORITY one-on-one tutoring in up to two classes per se- mester in most academic subiects Instruction in academic skill building and learning strategies
- Assistance in transferring to four-year colleges/universities
- Information and assistance in completing financial aid applications
- Academic advising and priority registration
- Culturally enriching field trips and extracurricular activities, as funds permit
- Appropriate referrals to other college offices/personnel and lo- cal community agencies
- Financial & economic awareness
- Access to TRIO quiet/study rooms
Student informed consent

VWCC Student Support Services staff may consult with each other in order to provide you with the best assistance available. Per-
sonal information will remain confidential unless we are legally required to make an exception. Exceptions are as follows:
- If there is reasonable cause to believe that you are a danger to yourself or others.
- If we suspect, or are informed of, abuse of children or vulnerable adults.
- If you are involved in criminal or civil proceedings, we may be required, by court subpoena, to release records and/or testify.
I give the VWCC Student Support Services program permission to obtain and/or release information on my behalf for the reasons listed. By signing below, Student Support Services has permission to:
- Obtain information necessary to establish eligibility for program services and report student progress information to the U. S. Department of Education to demonstrate program effectiveness.
- Share educational/limited information with those concerned about academic progress such as: Vice President’s office, Professors, Advisers, Financial Aid, Office of Disability Services etc.
This agreement remains in effect during my years as a student at Virginia Western Community College. If you have any questions about services, confidentiality or other legal or ethical concerns, please discuss this with any of the staff of VWCC Student Support Services.
Student Signature:

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent or Guardian Name:

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy

Virginia Western Community College

Application for Services

PROGRAM ELIGIBILITY

FINANCIAL ELIGIBILITY

ACADEMIC INFORMATION

OTHER

Needs Assessment Survey

Personal Inventory