Intake Form

Feather River College TRiO Student Support Services - Intake Form

Please contact program director, Billy Ogle, at (530)283-0202 ext 221 or wogle@frc.edu with any questions.
ADMINISTRATIVE DATA
Student Name:*
Date:*

MonthDayYear
Date
How did you hear about this program?*
Why are you interested in participating in FRC's TRiO Student Support Services Program?*
What is your current major?*
Why that particular major?*
If you have not chosen a major, what subjects interest you?
ACADEMIC DATA
What is your academic classification (freshman or sophomore)?*
Have you registered for classes?*
How many classes/credits are you taking?*
On average, how many hours a week do you plan to study per class?*
Tell us about any successes you may have experienced in school:*
Have you experienced any challenges in school?*
If yes, please explain:
What do you think will be your most difficult class?*
What will you do to ensure you are successful in that class?*
Do you feel prepared for the academic difficulty level of college classes?*
Do you need any academic support to help you to be successful in your courses/major?*
If you need academic support, please explain how we can help you:*
Do you have a support system to assist you in your decision to earn a college degree? Please explain:*
FINANCIAL DATA
Have you applied for financial aid?*

YesNo
If you have not applied, why not?
If you are receiving financial aid, which of the following are you receiving?*

Promise GrantPell GrantCal GrantScholarshipLoanOther
Have you completed the FAFSA for next year yet?*
Have you applied for any scholarships this year?*
Have you have taken out student loans? If so, what kind and for how much?*
Will you work while you're in school?*
If yes, how many hours per week?
If you are working, will you work on campus or off campus?
MOTIVATION
Why are you going to college? What was the defining moment that made you decide to enroll in college?*
What could prevent you from being successful in college (e.g.: family, grades, social life, money, self-motivation/procrastination excuse making, working too much)?*
What motivates you to get through these challenges to ultimately earn your degree from FRC and potentially transfer to a 4 year university? How do you motivate yourself when you feel like giving up?*
SKILL/NEED SELF-ASSESSMENT
Utilizing the following scale, check the response for each trait that best reflects you as a college student:

1 = very low 2 = low 3 = satisfactory 4 = high 5 = very high

Type a question*

	Very Low	Low	Satisfactory	High	Very High
Motivation
Self-discipline
Self-esteem
Confidence
Perseverance
Intellectual Interest
Study Habits
Attitude Toward College
Sense of Financial Security
Family Emotional Support

Which of the following areas do you feel that you can improve on? (check all that apply)*

Math SkillsListening SkillsStudy SkillsTime ManagementWriting SkillsConcentrationTest TakingBasic Computer SkillsReading SkillsMemorizationNote-takingProcrastination
Which of these services do you think you would utilize in the FRC TRiO SSS program? (check all that apply)*

TutoringAdvisingChoosing a MajorCareer GuidanceGoals/decision MakingFinancial Aid/Scholarship AdvisingExposure to Cultural Enrichment ActivitiesStress ManagementPeer MentoringCollege Finance ManagementFamiliarization with campus resources4-year Transfer AssistanceUnderstanding Degree RequirementsOther
The following is a list of participation requirements for the program:
- Complete at least one TRiO/SSS Orientation.
- Meet with your TRiO/SSS Academic Advisor at least 2 times per semester.
- Attend at least two workshops each year.
- Participate in at least one financial literacy workshop each year.
Are you willing to fully participate in TRiO SSS and attend all the required meetings and workshops?*

YesNo
Student Printed Name:*
Student Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Feather River College TRiO Student Support Services - Intake Form

ADMINISTRATIVE DATA

ACADEMIC DATA

FINANCIAL DATA

MOTIVATION

SKILL/NEED SELF-ASSESSMENT