Highland Community College-Highland-SSS-2025 Application Form

Application for Participation 2025-2026
Student Support Services (SSS) is a federally funded TRIO program under the Department of Education. The goal of this program is to:

· increase the retention and graduation rates of participants

· help students make the transition from one level of education to the next

The information you provide is confidential and is necessary for reporting purposes as well as eligibility determination. As part of this application, please complete the attached “Consent to Disclose Federal Tax Information (FTI) and FAFSA Data Form.”
Personal Information
Student Name*

First NameMiddle NameLast Name
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
Date of Birth*

MonthDayYear
mm-dd-yyyy
Highland Email Address*
Ex: LastName.FirstName@highlandcc.edu
Personal Email Address:*
example@example.com
Highland Student ID (9-digit number, i.e. 123-45-6789)*
MaleFemaleNo Response
US CitizenPermanent ResidentInternational Student
YesNo
WhiteBlack or African AmericanAsianNative Hawaiian or IslanderAmerican Indian or Alaskan Native
IndependentDependent
An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.

A Dependent student is a student who does not meet any of the criteria for an independent student. A dependent student is assumed to have the support of parents.
How many people are in your immediate family:*
Dependents: Include parents and their dependents

Independent: Include yourself, spouse, dependents
YesNo
YesNo
ScholarshipsGrantsPell GrantLoans
Education/Academic Information
No, I do not plan to transfer/Associate Degree onlyYes, I plan to transfer to a 4-year schoolUndecided
Disability Information
YesNo
YesNo
If you have not documented your disability with HCC, please complete the form listed here: https://highlandcc.edu/pages/disabilities-self-identification-form
Student Signature/Consent
I understand that the Student Support Services program will use the information provided on this application to assist in assessing any academic and career planning needs and that all of the information provided will be kept confidential. I release the following information to the Student Support Services (SSS) staff: high school and college transcripts, ACT scores, Highland Community College grade reports, financial assistance award notices and income information, disability documentation, and any other information from my academic records, as well as obtain college enrollment and degree information from National Student Clearinghouse pertaining to my enrollment in Student Support Services.

By signing below, I verify that all information provided on this application is true and complete.
Student Signature (First and Last Name)*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Please contact Amber Hutfles, Student Support Services Project Director with any questions at ahutfles@highlandcc.edu or at (785) 741-6110.
Consent to Disclose Federal Tax Information (FTI) and FAFSA Data for the TRIO Program
As required by HEA 20 USC 1098h(c)(1)(B), the student must give written consent in order to have Federal Tax Information (FTI) or Free Application for Federal Student Aid (FAFSA) data disclosed outside of the Financial Aid office.

STUDENT INFORMATION:
Name:*

First NameLast Name
Student ID:*
Student Email:*
example@example.com
Phone:*
(999)999-9999
By signing below, I, {name}, authorize and direct the Highland Community College financial aid office to disclose Federal Tax Information (FTI) and Free Application for Federal Student Aid (FAFSA) data for the purpose of verifying my eligibility to participate in TRIO programs.

I understand the disclosed records and information:

1. May include return information disclosed under IRC 26 U.S.C. 6103(l)(13); and

2. May only be disclosed for the specific purpose of verifying my eligibility to participate in TRIO programs; and

3. May not be used for any other purpose than that stated in item #2 above; and

4. May be provided only to individuals employed by Highland Community College under the TRIO program.

It is my intent that this consent form be interpreted to the extent permitted by applicable law, including but not limited to the Internal Revenue Code (IRC) of 1986, as amended, the Higher Education Act of 1965, as amended, the Family Educational Rights and Privacy Act (FERPA) of 1974, as amended, and the Privacy Act of 1974, as amended.
Student Signature - First and Last Name*

Clear
Date*

MonthDayYear
mm-dd-yyyy
The Highland Community College Student Support Services program is a Federal TRIO Program funded by a grant from the U.S. Department of Education. This program is funded 100% at an annual amount of $272,364 for the 2025-2026 school year.

Application for Participation 2025-2026

Personal Information

Education/Academic Information

Disability Information

Student Signature/Consent

Consent to Disclose Federal Tax Information (FTI) and FAFSA Data for the TRIO Program