TRIO Program Application & Needs Assessment

Name

First NameLast Name

Student ID

Email

example@example.com

Local Contact Information

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Personal Information

Date of Birth

Format 00/00/0000

Gender

Marital Status

Number of dependents living with you

Ethnicity

Are you Hispanic or Latino?

Race (select one or more)

Citizenship

Are you a U.S. citizen?

If "No", are you an eligible non-citizen?

Eligible Non-Citizen Status:

A U.S. permanent resident and you have an Alien Registration Receipt Card (I-551), or
A conditional permanent resident (I-551C), or
Another eligible non-citizen with an Arrival-Departure Record (I-94) from the Department of Homeland Security showing status has not expired, or "Cuban-Haitian Entrant."

Note: If you are in the U.S. on an F1 or F2 student visa, or a J1 or J2 exchange visitor visa, or a G series visa (pertaining to international organizations), you are not a citizen or eligible non-citizen and are not eligible to participate in the federal TRIO Student Support Services Program.

9-Digit Alien Registration Number

A-XXX-XXX-XXX

First Generation Verification

The term "first-generation college student" means:

1. An individual both of whose parents did not complete a baccalaureate (a bachelor or 4-year college) degree, or

2. In the case of any individual who regularly resided with and received support from only one parent, an individual whose only such parent did not complete a baccalaureate (a bachelor or 4-year college) degree.

Based on the definition above, are you a first generation college student

Has your mother received/earned a 4-year college degree (bachelor)?

Has your father received/earned a 4-year college degree (bachelor)?

Low-Income Verification

Have you completed the FAFSA for 2020-2021?

Other

Did you receive a Pell Grant?

According to the last U.S. Tax form filed, the number in the household is:

Documented Disability

Do you have a documented disability?

Have you submitted documentation of your disability to the Disability Support Services?

Note: Students with a disability may request accommodations through the Services for Differently Abled (DAO) at 718-270-5027.

Academic Plans

Are you admitted to Medgar Evers College?

If "Yes" are you currently enrolled in classes?

Do you plan to attend college?

What degree are you seeking at MEC?

What is your major?

If your major is an AA or AS, do you plan to transfer to a four-year college or university?

Transfer Institution

Major

Are you a high school graduate?

Highest grade completed

How many years of high school math did you take?

How many years of high school English did you take?

If you are not a high school graduate, did you complete a GED?

What year?

How long has it been since you have attended school?

How many miles do you commute roundtrip to school per day?

Are you a single parent?

Is English your first language?

If "No", what is your first language?

2. Personal History

Do you currently have stable housing?

Are you currently homeless?

Are you or have you ever been involved in the foster care system?

3. How can the Student Support Services Program best support your education goals? (Check all that apply)

Type a question

TRIO Student Support Services Program

How were you referred to MEC's TRIO Student Support Program?

TRIO programs you have participated in previously

Where did you participate in these programs?

(Institution name, city, and state)

Release of Information

I understand TRiO-SSS staff has access to information relevant to my academic status: enrollment data, test scores, transcripts, grades, financial aid verification, verification of disability status, and progress reports. Prior to my admission into the TRiO-SSS program, this information will be used to confirm my eligibility, and if accepted as a TRiO-SSS participant, this academic information will be used to help me meet my goals at Medgar Evers College.

Please Initial box(es) for permission(s) that you wish to grant to TRIO-SSS.

Student Signature

I certify that the information provided is, to the best of my knowledge, accurate and true

Digital Signature

1. Why did you decide to come/return to college?

2. What do you consider important characteristics of a successful student?

3. Do you have a specific career goal?

If "Yes", what is it?

If "No", what careers have you considered?

Academics

1. How would you summarize your academic strengths?

2. What MEC classes do you anticipate being a challenge for you?

3. Can you think of anything that might keep you from completing your college education?

4. What are some study skills you use to be successful?

5. How do you think your study skills could be improved?

6. Are you happy with your performance in school so far?

If "No", what is preventing you from being successful?

7. How many hours a week do you typically study?

8. Do you own a computer?

9. Do you have Internet access at home?

10. Are you confident in using the Internet?

11. Are you confident in your word processing skills?

Personal Responsibilities

1. Are you currently working or will you be working while you are a student?

If "Yes", how many hours will you work per week?

Place of employment

Approximately how many hours a week do you spend on outside activities?

Recreational hours

Sports hours

Community Services hours

Other hours

Reason for Applying

Tell us why you are applying to TRIO and what makes you a good fit for the program.

Digital Signature

Program Application & Needs Assessment

Academic Need Information

Student Profile