Cowley County Community College-SSS-Application Form

IMPACT/TRIO APPLICATION
Student Information
Student ID:
Full Name

First NameLast Name
Date of Birth

MonthDayYear
mm-dd-yyyy
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
(999)999-9999
Home Phone:
(999)999-9999
Personal Email:
example@example.com
Cowley Email:
example@example.com
Gender
Citizen Status
Ethnicity
First-Generation Verification

First generation college student means (1) A student neither of whose natural or adoptive parents received a bachelors degree; (2) A student who, prior to the age of 18, regularly resided with and received support from only one parent and whose supporting parent did not receive a bachelors degree; or (3) An individual who, prior to the age of 18, did not regularly reside with or receive support from a natural or adoptive parent.
Has your mother received/earned a bachelors degree (completed all 4 years):
Has your father received/earned a bachelors degree (completed all 4 years):
Disability Verificaiton

Providing your disability status is voluntary and will only be used to determine eligibility for TRIO. You are not required to share the type or nature of your disability. All information will remain confidential and will only be viewd by authorized program staff.
Do you currently receive academic accommodations through Cowley's Accessibility Coordinator, or do you have a 504 Plan or IEP that could qualify you for disability-related services?
Prior School Information
High School Equivalency
Date Graduated? (Month/Year):
If you haven't graduated yet, what is your anticipated date (Month/Year):
Have you attended any other college/academies/tech schools after high-school?
If you answered YES to the previous question, please provide School Name, Year Started, and Year Ended
Student or Future Student Status
Hours Enrolled
Campus Location Preference (Please select all that apply):
When was or will be your first semester at Cowley?
Please Ist (FALL/SPRING/SUMMER] and the YEAR
Have you taken any Cowley College Classes BEFORE applying to our program?
Declared or Preferred Major
Declared Career Choice
What's the highest degree you would like to receive?

Do you plan to continue your education beyond Cowley? If yes, please list your top 3 transfer schools?

Rows	College
1
2
3

Additional Questions
How did you hear about the IMPACT program?
Explain the reason(s) why you are applying to IMPACT/TRIO program?
Certification, Authorization, and Media Consent
I certify that the information I have provided on this application is, to the best of my knowledge, complete and accurate. Furthermore, I understand that by applying for the IMPACT/TRIO program, I authorize the program staff to obtain records or pertinent data necessary for this program. I acknowledge that this program is a federal grant program, and some of our records may be released to the United States Department of Education or TRiO Programs. Additionally, I grant the IMPACT/TRiO staff permission to communicate verbally or otherwise with staff faculty, and/or off-campus professionals on my behalf. I agree that if I am accepted into the IMPACT/TRiO program, the staff may include my name and/or picture or publications, including but not limited to the IMPACT websites. The websites are used to highlight student accomplishments and participation in campus and IMPACT/TRiO activities.

First NameLast Name
By typing my name, I acknowledge and agree to the terms outlined above and confirm that I am electonically signing this application.

IMPACT/TRIO APPLICATION

Student Information

Prior School Information

Student or Future Student Status

Additional Questions

Certification, Authorization, and Media Consent