TRIO SSS Application

Name *

First Name Middle Name Last Name

If different, please enter the name you wish to be called.

Maiden Name

Mid Student ID# *

MidMich Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Preferred Phone Number *

Area Code Phone Number

May we text you at your preferred phone number? *

Yes No

Alternate Phone Number

Area Code Phone Number

Birthdate *

Month Day Year

Select the gender that is reflected on your current legal documents such as your birth certificate, driver's license, etc. *

Male Female

Personal Pronouns

she/her/hers he/him/his they/them

Marital Status *

Single Married Divorced Separated Widowed

Hispanic or Latino? *

Yes No

Please select any additional ethnicities that apply. *

American Indian/Alaskan Native White/Caucasian Asian Black/African American Other

US Citizen *

Yes No

Permanent Resident

Yes No

Enter your A#

If you are not a US Citizen or a Permanent Resident, contact Mid's TRIO team for assistance by emailing trio@midmich.edu or calling (989) 317-9211.

Have either of your parents (natural or adoptive) received a Bachelor degree? *

Yes No

Do you have a documented disability that impacts your success in college? A disability can be of a physical, learning, psychological, or other nature.

Yes No

Are you currently registered with Student Accommodation Services at Mid?

Yes No

If you are not currently registered and would like information about services, contact Student Accommodation Services at accommodations@midmich.edu or (989) 317-4613.

Are you a current Mid Michigan College student? *

Yes No

What certificate, training credential, or associate degree do you plan to complete at Mid? *

After completing your chosen credential at Mid, do you plan to transfer? *

Yes No

If yes, what institution do you plan to transfer to?

According to the federal policy Higher Education Act(1), TRIO SSS must provide documentation of a student’s eligibility for the program to the U.S. Department of Education, which includes first generation and low-income status. We must verify this for all students who apply to TRIO SSS.

Definitions to help you determine your income status:

Dependent: A student that can be claimed by his or her parent(s) as an exemption on tax forms and/or does not meet one of the following criteria as an independent student.
Independent: A student is only considered independent according to Federal Financial Aid if they meet one of the following criteria:
- Is 24 years old or older by December 31 of the award year
- Is married
- Has legal dependent(s) other than their spouse
- Is a veteran of the Armed Forces of the United States
- Is an orphan or ward of the State of Michigan or ward of his/her residential State
- Has received a dependency override through Mid Michigan College Financial Aid

This section must be completed by the student if the student has been deemed independent by Financial Aid. If the student is dependent, the parent(s) must complete and sign this form. See above for definitions to determine your income status.

According to my most recent tax return form, the number of exemptions is *

Include the number of exemptions reported including self, spouse, and/or children.

According to my most recent tax return form, the TAXABLE income is *

Taxable income can be found on Form 1040 Line 43, Form 1040A Line 27, and Form 1040EZ Line 6.

Financial Disclosure *

To the best of my knowledge, I confirm that the information listed above accurately reflects my Annual Taxable Income for 2019.

Please choose any and all statements that you believe apply to you.

Academic Preparedness for College-Level Coursework

Low Admission Test Scores Low High School Grades High School GPA less than 2.5

Educational or Career Goals: I am interested in...

Career Interest Testing Choosing a Program of Study Resume Development Job Interview Skills Internships Job Shadowing Career Information

College Grades

I failed or withdrew from one or more courses I am on academic probation or financial aid warning My college GPA is less than 2.5

Other

I am in a program that requires a certain GPA, like Nursing I play sports for Mid I have been out of the academic pipeline for 5 or more years I earned a GED I have limited English proficiency I have participated in TRIO - Educational Talent Search or Students of Promise

Please check any and all of the following where you would like help or support.

Academic Support

Time Management Test-Taking Preparation Reading Comprehension Note Taking Test Anxiety Tutoring Help with Math

Academic Advising/Transfer

Choosing the right courses Unsure of goals Choosing a transfer school Setting up an educational plan College visits Filling out college applications

Financial Aid/Financial Literacy

Filling out the FAFSA Grants/Loans Counseling Scholarship Information Personal Budgeting Understanding Credit

Personal Support

Transportation Issues Single Parent Homeless Feeling Depressed or Sad Lack of Family/Friend Support Personal Counseling Family/Medical Issues Food Insecurity

I understand that applying to Mid Michigan College TRIO Student Support Services (SSS) does not guarantee acceptance into the program. I may be fully accepted, provisionally accepted, or denied based on the need for services, academic record, academic preparedness and progress, credit hours, financial aid status, and level of engagement.

Students on Financial Aid Warning, Approved Appeal, or on Academic Probation may be provisionally accepted until they are meeting Satisfactory Academic Progress.

I understand that if I do not meet the expectations and academic goals, I may be ineligible for the Mid TRIO-SSS program.

I am committed to my education, academic goals, and completion of my certificate and/or degree. I need to be fully engaged and strive for 100% classroom attendance and participation. I will meet the program expectations within my four years of eligibility:

Complete 100% of the courses I enroll in each semester or seek assistance if not, and maintain a semester cumulative GPA of 2.0 or higher
Complete ORT 101/102 (winter semester workshop series)
Contact with Success Coach two times per semester
Contact with Career Coach at least one time
Participate in one give-back (volunteering activity)
Participate in at least one workshop
Participate in at least one cultural enrichment activity
Participate in at least one of the following: job shadow or college/university visit

I hereby authorize the Mid TRIO SSS program staff to:

Gather information about my academic progress (placement test scores, GPA, earned credits, transcripts, tutoring sessions, etc.) and financial aid status prior to acceptance and during the program including, but not limited to, transfer to a four-year institution.
Information about academic accommodations, if I meet disability status.
Report my eligibility and financial aid status to the U.S. Department of Education.
Use photographs of me (individual and group) for informing others about TRIO SSS.
Use aggregate data to promote and inform Mid students, faculty, and staff about TRIO SSS.
Require that I provide documentation, upon request, to verify the information reported.

I understand that this form will become part of my TRIO SSS file at Mid Michigan College. I am aware that personal information provided to the Mid TRIO SSS Program will be protected under the Federal Education Rights & Privacy Act (FERPA) of 1974. No one will have access to the information unless they work for Mid Michigan College and/or the TRIO SSS Program and have a legitimate need to know under TRIO SSS and Mid Michigan College guidelines.

Confirm this option to continue. *

To the best of my knowledge, the information provided in this form, and any other supporting documentation, is true. I understand that this authorization is valid for the duration of my enrollment as well as five (5) years after I cease to be enrolled as a student.

Confirm this option to continue. *

I consent to completing this application with a digital signature and understand I have the option to print and sign with ink at a later date as needed/requested.

Signature *

Clear

Today's Date *

Month Day Year

Significant effort has been made to ensure this content meets accessibility guidelines. If you encounter a barrier you can report the barrier at midmich.edu/reportaccessibilitybarrier or contact TRIO SSS at (989) 386-6622 x225 or trio@midmich.edu.

Mid Michigan College strongly endeavors to broaden our diversity, promote equal opportunity, and provide a safe environment within its community. Mid is an equal opportunity employer and educational institution that prohibits any form of discrimination against any person on the basis of race, color, religion, sex, gender identity or expression, pregnancy, age, sexual orientation, marital or parental status, national origin, citizenship, genetics, disability, military/veteran status, or any other legally-protected status. This applies to the administration of and access to the College’s programs and activities; scholarship and loan programs; athletics; and in conditions of admission or employment. To learn more please see the Campus Non-Discrimination, Harassment, and Sexual Misconduct Policy at midmich.edu/titleix, and the Equal Employment Opportunity Policy at midmich.edu/eeo. Additionally, the College publishes an Annual Security that outlines safety and security initiatives, policies, protocols, and crime statistics and is available at midmich.edu/securityreport.

Mid strongly encourages anyone who observes or experiences any acts of harassment, discrimination, inequitable treatment, or sexual misconduct to report the incident and seek assistance from one of the College’s Title IX/Civil Rights Coordinator as follows: Tricia Farrell, Director of Compliance & Ethics/Title IX/Civil Rights Coordinator, Harrison Campus Main Building Room 205, Mt. Pleasant Campus Doan Center Room 105, (989) 386-6622 x394, mfarrell@midmich.edu.

TRIO SSS PARTICIPANT APPLICATION

PERSONAL DATA

ETHNIC GROUP

CITIZENSHIP

FIRST GENERATION STATUS

DISABILITY INFORMATION

EDUCATIONAL INFORMATION

INCOME VERIFICATION

Needs Assessment

Participant Agreement, Release of Information, & Affidavit of Truth Statement