TRIO Student Support Services

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1 TRIO Student Support Services Participant Application Office Use Only Student Name: S# Reviewed By: First-Gen & Low-Income Disabled & Low-Income Low-Income Only First-Gen Only Disabled Denied/Not Eligible Waitlist Date: Accepted Date: Date Stamp

2 Sign and return application with all required documents. TRIO Project Success Participant Application Changing lives through learning 900 West Orman Avenue (719) Pueblo, Colorado Student Support Services is a federally funded TRIO Program under the U.S. Department of Education that aids students in graduating from college. Program participants must meet certain requirements set forth by the Department of Education. To determine your eligibility, please fill out the following information completely. Incomplete applications will not be accepted. The information you provide is strictly CONFIDENTIAL. In order for your application to be reviewed, you must also attach a copy of your income verification (See Part 7). An incomplete application will not be accepted and all required documents must be included in order to be considered for entrance into the TRIO Program! If you have any questions, contact the TRIO office at or stop by in AB PART 1: PERSONAL DATA INFORMATION Student S# Applicant Name: (Last) (First) (MI) Address: (Street/P.O. Box) (City) (State) (Zip Code) Home Phone: ( ) Cell Phone: ( ) Pueblo Community College Address: (You will be contacted through as well as your home or cellphone number to notify you of upcoming events and workshops with the program.) Gender: Male Female Birth date: / / MM DD YY PART 2: ETHNIC and RACE Are you identified as (Please mark YES or NO to all items): Ethnicity Are you: Hispanic/Latino? (Hispanic/Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish cultural or region, regardless of race.) Race Are you: American Indian or Alaska Native? (American Indian/Alaskan Native refers to a person having origins in any the original peoples of North and South America, including Central America, and who have tribal affiliation.) Asian? (Asian refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.) Race Are you: Black or African American? (Black or African American refers to a person having origins in any of the black racial groups of Africa) White? (White refers to a person having origins in any of the original peoples of Europe, the Middle East, or North Africa to include Hispanic/Latino) Native Hawaiian or Other Pacific Islander? (Native Hawaiian or Other Pacific Islander refers to a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

3 PART 3: CITIZENSHIP Are you a U.S. citizen: Yes No If No, are you an eligible non-citizen? Yes No Alien Registration Number: PART 4: EDUCATIONAL INFORMATION Are you a high school graduate? Yes No If No, did you receive a GED? Yes The year the GED was received: City & State where GED was attained: Have you attended a college other than PCC? Yes No If YES, where? Academic Classification: First Time Student Returning Student Date you started at PCC Have you taken the Accuplacer test? Yes No Do you plan to attend college? Full-time Three-quarter time Half-time Less than half-time Target graduation date at PCC? Do your goals include transferring to a 4-year college? Yes No Which PCC degree or certificate are you planning to pursue? (Check the one that applies to you) Associate of Arts Degree (AA transfer degree) What is your field of study? Associate of General Studies Degree (AGS transfer degree) What is your field of study? Associate of Science Degree (AS transfer degree) What is your field of study? Associate of Applied Science Degree (AAS non-transferable degree) What is your field of study? Certificate Program (what is your field of study?) Have you been part of another TRIO program? Yes No If YES, where? Which program? Student Support Services Educational Opportunity Center Upward Bound Talent Search Were you referred to TRIO Project Success? Yes No If Yes, by whom? Program

4 PART 5: FIRST-GENERATION VERIFICATION The term first generation college student means: 1. A student neither of whose natural or adoptive parents received a baccalaureate (bachelor s or 4-year college) degree, or 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 baccalaureate degree, or 3. An individual who, prior to the age of 18, did not regularly reside with or receive support from a natural or an adoptive parent. Highest educational level for your natural or adoptive parents. (Check only one for each parent): Father Mother High School College (Bachelor's Degree or higher) None of the above PART6: DISABILITIES VERIFICATION Do you have any documented physical and/or learning disabilities? Yes No If yes, is the disability information on file with the Pueblo Community College s Disability Resource Office? Yes No PART 7: INCOME VERIFICATION One purpose of the federal TRIO programs is to increase opportunity in education for students from low-income backgrounds; consequently, federal legislation requires that TRIO programs verify the financial eligibility of applicants before they can be admitted. In many cases, the Federal Financial Aid Form (FAFSA) on file with the university suffices, but in other cases, additional information is needed. It is a requirement that you bring in: (A) signed copy of your and your parent s (if applicable) 2014 Federal Tax Return, OR (B) verification of income from another government source, OR (C) a signed financial aid application (Student Aid Report - SAR). If you are under the age of 25, please talk to a TRIO representative for specific information on what income verification you will need to submit. The information we request will be used only to determine or verify eligibility for TRIO. All information is confidential and is never passed on to any other agency. The U.S. Department of Education provides more information about TRiO and eligibility requirements on its web site: (Effective January 28, 2015 until further notice) Size of Family Unit 48 Contiguous States, D.C., and Outlying Jurisdictions Alaska Hawaii 1 $17,655 $22,080 $20,325 2 $23,895 $29,880 $27,495 3 $30,135 $37,680 $34,665 4 $36,375 $45,480 $41,835 5 $42,615 $53,280 $49,005 6 $48,855 $61,080 $56,175 7 $55,095 $68,880 $63,345 8 $61,335 $76,680 $70,515

5 PART 8: FINANCIAL AID STATUS (select all that apply) I have applied for Financial Aid I have been approved for Financial Aid I did not apply for Financial Aid I have not heard from Financial Aid I am on Financial Aid probation or suspension I have not been approved for Financial Aid PART 9: Why Do You Want to Join TRIO (to include self identified academic need)? Please select all that apply. Academic Advisement/Coaching Financial Literacy Cultural Events/Workshops Financial Aid Advisement Tutoring Transfer Advisement Career Counseling Transition Concerns Campus Tours four-year colleges Help in maintaining or improving GPA for specific degree program or four-year college acceptance High school GPA was below 3.0 I have a GED Declining college grades Major/Degree Exploration Advice and assistance in course selection I did not take college preparation course in high school Returning to college after an extended absence English is a second language PART 10: In your own words, tell us how the TRIO program will help you become successful.

6 PART 11: PARTICIPANT AGREEMENT & RELEASE OF INFORMATION Name S# (Please Print) I authorize the TRIO Project Success Program staff to gather information concerning all my academic progress (standardized test scores, grade point average, earned credit, transcripts, tutoring, etc.) and financial aid status prior to my participation in the program. I also grant permission to PCC s Disability Resources Office to release information to TRIO Project Success if I fall under the disability status. I understand that this information is used to help determine my eligibility for the program and kept strictly confidential. (student signature) I grant permission for the TRIO Project Success Program to gather information for follow-up whenever appropriate, including, but not limited to, transfer and progress to 4-year institutions. (student signature) I am aware that my eligibility, GPA, and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations. I certify that the information provided on this application is true and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information reported. (student signature) I also, hereby authorize the use of my photographic image in any and all publications, such as the monthly newsletter, newspaper articles, and campus-wide notices. I authorize Pueblo Community College to use my name, photo, or information about me in promotion of the college through radio, television, or other printed materials. I understand that my picture could come from a digital image such as my file or from photos taken on various field trips and social events. (student signature) I am aware that personal information provided to the TRIO Project Success Program will be protected under the Family Education Rights & Privacy Act (FERPA) of No one will have access to the information unless they work with or for Pueblo Community College and TRIO Project Success Program. PART 12: AFFIDAVIT OF TRUTH STATEMENT The information provided on this form is, to the best of my knowledge, accurate and true. Student: (Signature) (Date)

7 PART 13: APPLICATION SUBMISSION INFORMATION Submit this application to: TRIO Student Support Services/Project Success Pueblo Community College 900 West Orman Avenue, Room AB-174 Pueblo, Colorado Your application will be incomplete and not processed if: You have not filled out all sections You have not initialed and signed application in appropriate places You have not included signed income verification for the year 2014 tax year Student Signature Today s Date TRIO Staff Member Signature A TRIO Staff member will review your application and if you meet the minimum criteria set by US Department of Education and the TRIO program, you will be invited to an Information Session. At the Information Session, you will learn more about the TRIO Program and the expectations if you become a participant of the program. If you have any questions about the selection criteria into the program, please consult with a TRIO Staff Member. Thank you for your interest in becoming a member of the TRIO Program!

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