TRIO SSS Application

TRIO SSS PARTICIPANT APPLICATION
PERSONAL DATA
Name*

First NameMiddle NameLast 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

CityState / Province

Postal / Zip Code
Preferred Phone Number*

Area CodePhone Number
May we text you at your preferred phone number?*

YesNo
Alternate Phone Number

Area CodePhone Number
Birthdate*

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

MaleFemale
Personal Pronouns

she/her/hershe/him/histhey/them
Marital Status*

SingleMarriedDivorcedSeparatedWidowed
ETHNIC GROUP
Hispanic or Latino?*

YesNo
Please select any additional ethnicities that apply.*

American Indian/Alaskan NativeWhite/CaucasianAsianBlack/African AmericanOther
CITIZENSHIP
US Citizen*

YesNo
Permanent Resident

YesNo
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.
Where did you hear about TRIO-SSS? (for example, please select one of the following)
If you chose Professor or Other, please list the name of the person who referred you, or describe further details so we can better promote TRIO-SSS to future students.
FIRST GENERATION STATUS
Have either of your parents (natural or adoptive) received a Bachelor degree?*

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

YesNo
Are you currently registered with Student Accommodation Services at Mid?

YesNo
If you are not currently registered and would like information about services, contact Student Accommodation Services at accommodations@midmich.edu or (989) 317-4613.
EDUCATIONAL INFORMATION
Are you a current Mid Michigan College student?*

YesNo
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?*

YesNo
If yes, what institution do you plan to transfer to?
INCOME VERIFICATION
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 the tax return form used on the most recent FAFSA, the number of exemptions is*
Include the number of exemptions reported including self, spouse, and/or children. The FAFSA utilizes prior-prior year tax information. For example, if you apply to TRIO-SSS during the 2022-2023 academic year, you would use 2020 tax return information.
According to the tax return form used on the most recent FAFSA, the TAXABLE income is*
Taxable income can be found on Form 1040 Line 43, Form 1040A Line 27, and Form 1040EZ Line 6. The FAFSA utilizes prior-prior year tax information. For example, if you apply to TRIO-SSS during the 2022-2023 academic year, you would use 2020 tax return information.
Financial Disclosure*

To the best of my knowledge, I confirm that the information listed above accurately reflects my Annual Taxable Income as reported on the most recent, applicable FAFSA.
Needs Assessment
Please choose any and all statements that you believe apply to you.
Academic Preparedness for College-Level Coursework

Low Admission Test ScoresLow High School GradesHigh School GPA less than 2.5
Educational or Career Goals: I am interested in...

Career Interest TestingChoosing a Program of StudyResume DevelopmentJob Interview SkillsInternshipsJob ShadowingCareer Information
College Grades

I failed or withdrew from one or more coursesI am on academic probation or financial aid warningMy college GPA is less than 2.5
Other

I am in a program that requires a certain GPA, like NursingI play sports for MidI have been out of the academic pipeline for 5 or more yearsI earned a GEDI have limited English proficiencyI 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 ManagementTest-Taking PreparationReading ComprehensionNote TakingTest AnxietyTutoringHelp with Math
Academic Advising/Transfer

Choosing the right coursesUnsure of goalsChoosing a transfer schoolSetting up an educational planCollege visitsFilling out college applications
Financial Aid/Financial Literacy

Filling out the FAFSAGrants/Loans CounselingScholarship InformationPersonal BudgetingUnderstanding Credit
Personal Support

Transportation IssuesSingle ParentHomelessFeeling Depressed or SadLack of Family/Friend SupportPersonal CounselingFamily/Medical IssuesFood Insecurity
Participant Agreement, Release of Information, & Affidavit of Truth Statement
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*

MonthDayYear
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) 317-9211 or trio@midmich.edu.

In its commitment to providing a safe environment, Mid Michigan College actively endeavors to broaden our diversity, promote equal opportunity, and prohibit any form of discrimination in its programs, activities, and conditions of admission or employment. Learn more about these efforts and policies by visiting midmich.edu/eeo, midmich.edu/titleix, midmich.edu/securityreport.
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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