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 NAME Type Your MIDDLE INITIAL Type 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?

Month Day Year
Date
What is your ETHNICITY? Please check all that describe you.

Alaskan Native American Indian Asian Black (Non-Hispanic) Hispanic Pacific Islander Native Hawaiian White Native American
I identify my GENDER as:

Female Male Transgender Other
Do you have a DOCUMENTED LEARNING DISABILITY?

YES NO
If YES, are you registered with the SIC ADA Coordinator?

YES NO
Do you have an IEP? Individualized Education Plan

YES NO
STEP 3
Are you a U.S. Citizen?

YES NO
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?

YES NO
What is your PERMANENT RESIDENT ALIEN NUMBER?
STEP 4
Has your MOTHER received /earned a 4-year college degree?

YES NO
Has your FATHER received/earned a 4-year college degree?

YES NO
Which parent did your regularly reside with or receive support from during your childhood (i.e. until your were 18 years old). Please check only ONE box.

MOTHER FATHER BOTH MOTHER AND FATHER NEITHER MOTHER OR FATHER
STEP 5

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

YES NO
Do you have children or other dependents (other than a spouse) who receive more than half of their support from you?

YES NO
At any time since reaching 13 years of age, were you an orphan, in foster care, or a ward of the court?

YES NO
Prior to reaching 18 years of age, were you an emancipated minor or did you have a court-appointed legal guardian?

YES NO
Are you serving on active duty (for other than training purposes) in the U.S. Armed Forces?

YES NO
Are you a U.S. Armed Forces veteran who was on active duty and was released under a condition other than dishonorable?

YES NO
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)?

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

YES NO
Are you homeless (i.e., you lack a fixed regular, and adequate nighttime residence) or are at risk of becoming homeless?

YES NO
STEP 6
Please check all the provided services that you are interested in:

FINANCIAL AID ASSISTANCE TIME MANAGEMENT TUTORING PERSONAL COUNSELING STUDY SKILLS CULTURAL ACTIVITIES TRANSFER ASSISTANCE PEER MENTORING FINANCIAL LITERACY ACADEMIC ADVISING CAREER COUNSELING COMPUTER LAB
STEP 7

Please answer the following questions about the educational career.
What year/semester was your first at SIC? (after High School Graduation)
What is your major?
Do you plan on graduating with an Associates Degree?

YES NO
What type of Associates Degree do you plan on earning?

Arts Science Applied Science Nursing Undecided
What is your target graduation semester and year?
After you leave SIC do you plan on receiving a Bachelor's Degree?

YES NO
Do you plan on receiving a certificate (less than 2-years) at SIC?

YES NO
STEP 8

Please read the following statement, 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

Clear
Date (Month/Date/Year)

Month Day Year
Date
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
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TRIO/STUDENT SUPPORT SERVICES ONLINE APPLICATION SOUTHEASTERN ILLINOIS COLLEGE

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

STEP 7

STEP 8

THANK YOU