TRIO Program Application & Needs Assessment

Program Application & Needs Assessment
Name

First Name Last Name
Student ID
Email
example@example.com
Local Contact Information
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Personal Information
Date of Birth
Format 00/00/0000
Gender

Male Female
Marital Status

Married Single Widowed Divorced
Number of dependents living with you
Ethnicity
Are you Hispanic or Latino?

Yes No
Race (select one or more)

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Citizenship
Are you a U.S. citizen?

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

Yes No
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

Yes No
Has your mother received/earned a 4-year college degree (bachelor)?

Yes No Did not reside with or receive support from mother
Has your father received/earned a 4-year college degree (bachelor)?

Yes No Did not reside with or receive support from father
Low-Income Verification
Have you completed the FAFSA for 2020-2021?

Yes No
Did you receive a Pell Grant?

Yes No
According to the last U.S. Tax form filed, the number in the household is:
Documented Disability
Do you have a documented disability?

Yes No
Have you submitted documentation of your disability to the Disability Support Services?

Yes No
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?

Yes No
If "Yes" are you currently enrolled in classes?

Yes No
Do you plan to attend college?

Full-time (12+ credits) Three-quarter time (7-11 credits) Half-time (6 credits) Less than half-time (Less than 6 credits)
What degree are you seeking at MEC?

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

Yes No
Transfer Institution
Major
Academic Need Information

1. Education History
Are you a high school graduate?

Yes No
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?

Yes No
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?

Yes No
Is English your first language?

Yes No
If "No", what is your first language?
2. Personal History
Do you currently have stable housing?

Yes No
Are you currently homeless?

Yes No
Are you or have you ever been involved in the foster care system?

Yes No
3. How can the Student Support Services Program best support your education goals? (Check all that apply)
Type a question

Academic Advising Adjusting to college Clarification of career goals Financial aid/scholarship assistance Improving GPA Improving time management Learning resources/services Selecting a major/career Study groups Transfer advising Tutoring: Other Courses Tutoring: Math
TRIO Student Support Services Program
How were you referred to MEC's TRIO Student Support Program?
TRIO programs you have participated in previously

Educational Opportunity Center Educational Talent Search Student Support Services Upward Bound None
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.
I give permission to TRiO-SSS staff to exchange information pertinent to my educational goals, plans and progress with MEC faculty and staff from various departments including Registrar, Financial Aid, Academic Advising, Differently Abled Office Services, Institutional Research/Planning, Testing, and InstructionalDepartments. I give permission to TRiO-SSS staff to exchange information with other colleges and universities that I apply to and enroll in to assist in transfer planning and verify admission. I give permission to TRIO-SSS to print my name and picture in TRiO-SSS newsletters, within the TRIO course website or in other documents regarding academic accomplishments (scholarships, academic honors, graduation, events, etc.)
Student Signature

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

College and Career Goals
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?

Yes No
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?

Yes No
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?

Yes No
9. Do you have Internet access at home?

Yes No
10. Are you confident in using the Internet?

Yes No Somewhat
11. Are you confident in your word processing skills?

Yes No Somewhat
Personal Responsibilities
1. Are you currently working or will you be working while you are a student?

Yes No
If "Yes", how many hours will you work per week?

0-11 hours 11-19 hours 20-29 hours 30-40 hours 40+ hours
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
I was an independent student (typically age 24 or older, married or emancipated; parental income is NOTREPORTED on the FAFSA) I was a dependent student (younger than 24, unmarried or not emancipated; parental income IS REPORTEDon the FAFSA)
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Program Application & Needs Assessment

Academic Need Information

Student Profile