Citrus Community College District-STEM-SSS-Application Form

TRIO STEM Application
The Citrus College TRIO STEM student support services program is designed to assist first-generation, Pell Grant recipient/Financial need, and/or students with disabilities majoring in STEM and Health Sciences by offering a variety of services tailored to meet their individual needs.

Students who participate will:

• Receive personalized and regular support from TRIO facilitators
• Have access to personalized math and science tutoring
• Be part of a motivated cohort of peers working towards degree/certificate completion

QUESTIONS?
Email trio@citruscollege.edu
or contact a TRIO facilitator

Karina Quevedo · senior TRIO facilitator
kquevedo@citruscollege.edu · (626) 857-4007

SUBSCRIBE & FOLLOW
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TRIO STEM Eligibility:
- Have a declared STEM (science, technology, engineering, and mathematics) or health sciences (dental assist, pre-allied health, nursing, etc.) major
- Identify with at least one of the following:
  - First-generation college student
  - Pell Grant recipient/Financial need
  - Registered with DSPS
- Must be a U.S. citizen or permanent resident
- Willing to meet regularly with program staff and participate in project activities.
STUDENT INFORMATION
First and Last Name*

First NameLast Name
Citrus Student ID *
Citizenship*
Citrus College Email*
example@example.com
Personal Email *
example@example.com
Cell Phone Number*
(999)999-9999
Can we send text messages to the cell phone number you provided?*

YesNo
Residential Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
mm-dd-yyyy
Gender*
Do you have children?*

YesNo
If yes, what year were they born?
Do you identify as Hispanic?*

YesNo
Racial-Ethnic Background (Check all that apply)*

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachmentAsian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, & VietnamBlack or African American - A person having origins in any of the Black racial groups of AfricaNative Hawaiian or Other Pacific Islander -A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific IslandsWhite - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
(999)999-9999
ACADEMIC INFORMATION
Please indicate the year you obtained a high school diploma, GED, or Other*
Last High School Attended:*
High School and City
Have you attended other colleges or universities?*

YesNo
If yes, list all colleges and universities you have attended
Have you earned an AA/AS?*

YesNo
If yes, from what college or universities?
Have you earned a BA/BS?*

YesNo
If yes, from what college or university?
What is your current Citrus College major? *
What is your Citrus College GPA?*
For the current term, what courses are you enrolled in and what are your current grades?
Select all programs and opportunities you have participated in (current or past):*

CalWORKsDSPSEOPS/CARE/NextUpFoster and Kinship Care Education (FKCE)Guardians ScholarsHonors ProgramPathways to STEM at Citrus CollegePromise ProgramProject SSOAR at Citrus CollegeRising ScholarsStudent Life/Student ClubsStudent VeteranSummer Research Experience at Citrus CollegeNone of the above
ELIGIBILITY
Has Parent #1 graduated from college with a 4-year degree?*

YesNoN/A
Has Parent #2 graduated from college with a 4-year degree?*

YesNoN/A
Before the age of 18, with whom did you reside? Select all that apply*

Parent #1Parent #2Other
Have you applied for financial aid at Citrus College for the current academic year?*

YesNo
Are you registered with DSPS at Citrus College?*

YesNo
EDUCATIONAL GOALS
What degree are you seeking at Citrus College?*
Anticipated last semester at Citrus College?*
Example: Spring 2028
Do you intend to transfer to a 4-year institution?*

YesNo
If yes, what transfer institutions are you interested in? Select all that apply

University of California (UC)California State University (CSU)Private in-state universityOut of state universityNot sureNot interested
What is your anticipated transfer major?*
FINANCIAL INFORMATION
Are you 24 years of age or older?*

YesNo
As of today, are you married? (If you are separated, but not divorced also answer “Yes”)*

YesNo
Are you currently serving on active duty in the U.S. Armed Forces for purposes other than training?*

YesNo
Are you a Veteran of the U.S. Armed Forces?*

YesNo
Do you have children who will receive more than half of their support from you?*

YesNo
Do you have dependents (other than your children or spouse) who will live with you and who receive more than half of their support from you?*

YesNo
At any time since you turned age 13, were both your parents deceased, were you in foster care or were you a dependent of the court?*

YesNo
Are you or were you an emancipated minor as determined by a court of law?*

YesNo
Are you or were you in legal guardianship as determined by a court of law?*

YesNo
Within the past two years, were you determined to be an unaccompanied youth who was homeless OR were self-supporting and at risk of being homeless?*

YesNo
Independent student vs. Dependent student
- If you answered YES to any of the questions in the Financial Information section above, you're considered an Independent student and will need to provide your own tax return information below.
- If you answered NO to any of the questions in the Financial Information section above, you're considered a Dependent student and will need to provide your parent or guardian tax return information below.
What is the total number of persons (including you) in your family?*
What tax year is the filed tax return you're using for this application?*
We accept tax returns from up to two years prior.
What is the Taxable Income? (This is NOT your adjusted gross income)*
You can find this information on: IRS Form 1040 & 1040SR Tax return: Line 15
SHORT ANSWER QUESTIONS
What are your educational goals? What motivates you to successfully reach these goals?*
80 - 150 words required
What personal or academic challenges must you overcome in order to reach your educational goals? *
80 - 150 words required
Is there anything you think the project staff may need to know about you that would help them better assist you? If yes, please explain.*
80 - 150 words required
Check all areas in which you feel TRIO STEM staff may be able to assist you*

Academic Guidance - Get advice to stay on track to graduate and transfer on time.Tutoring - Receive personal one-on-one and online tutoring in STEM and health science subject areas at no cost to you.Financial and Economic Literacy - Learn about managing a budget and making wise financial decisions.Learning Styles and Study/Test Taking Skills - Assistance in identifying your style of learning and some strategies to study and take tests successfully.Graduation & Transfer to 4 Year College -Receive assistance in graduation from Citrus College and transfer to college/university.Financial Aid Information and Assistance Applying - Assistance completing FAFSA annually. Learn about scholarships & other financial aid options.
REQUIRED DOCUMENTS
Submit the following files *
Before uploading your documents, view the "Apply to TRIO STEM and Required Application Documents" tab on the main STEM webpage."
- Copy of your Financial Aid Award Overview
- Unofficial transcripts from all colleges you have attended
- Copy of your Comprehensive Student Education Plan (CSEP)
- Optional: Citrus College DSPS Academic Accommodation Plan (AAP) or Verification of Disability Services letter
Financial Aid Award Overview*

Cancelof
Unofficial transcripts

Cancelof
Comprehensive Student Education Plan

Cancelof
Optional: Citrus College DSPS Academic Accommodation Plan (AAP) or Verification of Disability Services letter

Cancelof
AUTHORIZATION OF INFORMATION/STATEMENT OF AUTHENTICITY
In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services Program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties.
Please select:*

By submitting this application, I attest that the information I have provided is true and correct to the best of my knowledge. I attest that the documents I have presented for verification of eligibility are genuine and relate to me. I am aware that any false documents in connection with eligibility will be cause for my dismissal from the Student Support Services program.
Date of Application*

MonthDayYear
mm-dd-yyyy

TRIO STEM Application

STUDENT INFORMATION

ACADEMIC INFORMATION

ELIGIBILITY

EDUCATIONAL GOALS

FINANCIAL INFORMATION

SHORT ANSWER QUESTIONS

REQUIRED DOCUMENTS

AUTHORIZATION OF INFORMATION/STATEMENT OF AUTHENTICITY