TRIO/STUDENT SUPPORT SERVICES ONLINE APPLICATION SOUTHEASTERN ILLINOIS COLLEGE

TRIO/STUDENT SUPPORT SERVICES ONLINE APPLICATION SOUTHEASTERN ILLINOIS COLLEGE
3575 College Road -- Harrisburg, IL 62946
www.sic.edu/trio -- 618-252-5400 ext. 2432
STEP 1

Please answer the following questions about yourself.
NAME

Type Your FIRST NAMEType Your MIDDLE INITIALType Your LAST NAME
What is your MAILING ADDRESS?
STREET ADDRESS
CITY
STATE
ZIP CODE
What is your HOME PHONE NUMBER?
What is your CELL PHONE NUMBER?
What is the BEST EMAIL ADDRESS to contact you?*
example@example.com
STEP 2

Please answer the following questions about yourself
What is your SIC STUDENT ID NUMBER?
What is your DATE OF BIRTH?

MonthDayYear
What is your ETHNICITY? Please check all that describe you.

Alaskan NativeAmerican IndianAsianBlack (Non-Hispanic)HispanicPacific IslanderNative HawaiianWhiteNative AmericanOther
I IDENTIFY my GENDER as Gender .

My PREFERRED PRONOUNS are Pronoun , Pronoun , andPronoun .
Do you have a DOCUMENTED LEARNING DISABILITY?

YESNO
If YES, are you registered with the SIC ADA Coordinator?

YESNO
Do you have an IEP? Individualized Education Plan

YESNO
STEP 3
Are you a U.S. Citizen?

YESNO
If you are not a U.S. Citizen, please answer the following questions about yourself. If you are a U.S. Citizen, please skip ahead to STEP 4.
Are you a PERMANENT RESIDENT?

YESNO
What is your PERMANENT RESIDENT ALIEN NUMBER?
STEP 4
Has your MOTHER received /earned a 4-year college degree?

YESNO
Has your FATHER received/earned a 4-year college degree?

YESNO
Which parent did you regularly reside with or receive support from during your childhood (i.e. until your were 18 years old). Please check only ONE box.

MOTHERFATHERBOTH MOTHER AND FATHERNEITHER MOTHER OR FATHER
STEP 5

PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOURSELF.
Are you married?

YESNOOther
Do you have children or other dependents (other than a spouse) who receive more than half of their support from you?

YESNO
At any time since reaching 13 years of age, were you an orphan, in foster care, or a ward of the court?

YESNO
Prior to reaching 18 years of age, were you an emancipated minor or did you have a court-appointed legal guardian?

YESNO
Are you serving on active duty (for other than training purposes) in the U.S. Armed Forces?

YESNO
Are you a U.S. Armed Forces veteran who was on active duty and was released under a condition other than dishonorable?

YESNO
Are you in college and working on a master's (e.g. M.A., M.S.), professional (e.g., M.D., J.D. or Doctoral Degree)?

YESNO
Are you less than 18 years of age and have no parent or guardian?

YESNO
Are you homeless (i.e., you lack a fixed regular, and adequate nighttime residence) or are at risk of becoming homeless?

YESNO
STEP 6
Please check all the provided services that you are interested in:

FINANCIAL AID ASSISTANCETIME MANAGEMENTTUTORINGPERSONAL COUNSELINGSTUDY SKILLSCULTURAL ACTIVITIESTRANSFER ASSISTANCEPEER MENTORINGFINANCIAL LITERACYACADEMIC ADVISINGCAREER COUNSELINGCOMPUTER LABFREE PRINTING
STEP 7

Please answer the following questions about the educational career.
What year/semester was your first at SIC? (after High School Graduation)
Type the year you started or anticipate starting classes at SIC.
What is your major?
Type the major you would like to pursue. Not Decided? Type undecided.
Do you plan on graduating with an Associates Degree?

YESNO
What type of Associates Degree do you plan on earning?

ArtsScienceApplied ScienceNursingUndecided
What is your target graduation semester and year?
Type the semester which you anticipate graduating. (approximately)
After you leave SIC do you plan on receiving a Bachelor's Degree?

YESNO
Do you plan on receiving a certificate (less than 2-years) at SIC?

YESNO
STEP 8

Please read the following statement and then sign and date below.
By signing this application, I attest that all the information on this application is true. I give permission to release my name and/or picture to provide recognition in newsletters, webpages and/or other publications. Moreover, I authorize the release of the student’s official academic records to the office of TRIO/Student Support Services. I understand that the information in these records will be used only to assess the student’s need for program services, discern the student’s educational progress, evaluate the effectiveness of program activities, and fulfill program-reporting requirements.
Signature

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Date (Month/Date/Year)

MonthDayYear
THANK YOU

Thank you for completing the SIC TRIO Application. The TRIO Advisor will be in contact with you shortly. If you do not receive a response within two weeks, please email TRIO Advisor, Angie Dunk at angie.dunk@sic.edu for assistance.
Name*

First NameLast Name
Should be Empty:

TRIO/STUDENT SUPPORT SERVICES ONLINE APPLICATION SOUTHEASTERN ILLINOIS COLLEGE

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

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STEP 8

THANK YOU