TRIO-SSS Application

TRIO-SSS Student Application

*Indicates a required field
TRIO-SSS is 100% funded by the United States Department of Education is hosted by Iowa Lakes Community College. Funding for 2022-23 is $335,086.00
Part 1: Personal Data
Name*

First NameMiddle InitialLast Name
Will you be living in the dorms*

YesNo
Campus
Room Number
Local Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is this the same as your permanent address?

YesNo
Permanent Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Email*
example@example.com
Social Security Number (xxx-xx-xxxx)*
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Are you a U.S. Citizen*

YesNo
If you answered “NO”, are you an eligible non-citizen? Alien Registration #:
Ethnic Group*

American Indian or Alaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhite
Mark all that apply to you.

ESL (English as a second language)VeteranFoster ChildHomeless
Have you attended another college?*

YesNo
If yes, where?
Degree/Certificates you received there:
Have you participated in the following TRIO programs?

Talent SearchUpward BoundStudent Support ServicesOther
Do you plan on or are you thinking about transferring to a four-year institution?*

YesNo
Did you graduate high school?*

YesNo
Part 2: Need
Please check areas of need:*

Low high school gradesAcademic Proficient TestsFailing gradesLimited English proficiencyLow college gradesLow admission test scoresLack of academic preparedness for college level workNeed for academic support to raise grade(s)/tutoringOut of academic pipeline for 5 or more yearsLack of clear educational and/or career goalsOther
Part 3: Verification
Do you have a documented mental, physical and/or learning disability?*

YesNo
If yes, check the services you are receiving for your disability

AccommodationsVocationalRehabilitationSAVEOther
Have you applied for Financial Aid and completed the FAFSA form*

YesNo
Part 4: First Generation Student Verification
The term “first generation college student” means:
a. An individual whose parents did not complete a baccalaureate (bachelor’s or 4-year college) degree, or
b. In the case of an individual who regularly resides with and receives support from only one parent, that parent did not complete a bachelor’s or4-year college degree
Please check if either parent has a Bachelor’s degree or higher. (If neither parent has a Bachelor’s degree or higher, you are considered first generation.)

FatherMotherNeither parent has a 4 year degree
Under the above definition, I am a "first generation college student."*

YesNo
Part 5: Dependency and Financial Verification
Select one:*

Dependent Student - Typically younger than 24, unmarried, parental income is reported on the FAFSA. We need YOUR PARENTS’ taxable income amount from the previous yearIndependent Student - An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.
Independent Student Status
I am considered an independent student. Please check how you are considered an independent student. (If you are unable to check any of the boxes below, you are considered a dependent student.)*

Have children/dependents you supportCurrently Active Duty or U.S. VeteranAt risk or considered Homeless by School/HUDOrphan/Ward of CourtOver the age of 24In legal guardianshipMarriedEmancipated minorMasters or Doctorate program
A: Students taxable income amount for the previous year:*
B: Total number of individuals in household (Include parent(s), yourself, and other dependents).*
Dependent Student Status
If you are considered a dependent student, please have your parents complete the TRIO-Student Support Services Financial Eligibility Verification Form. This form needs to be completed and returned before we can process your application. The form can be returned to room 9 on the Estherville campus or room 240 on the Emmetsburg campus.
Total Number of Individuals in household?*
(1) Parent/Guardian Name*

First NameLast Name
Phone/Cell Number*
Please enter a valid phone number.
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Part 6: Release of Information & Affidavit of Truth Statement
By signing this application, I verify that the information provided is true and accurate to the best of my knowledge. I authorize TRIO-SSS staff to gather and verify information concerning the eligibility requirements for the program; income, documented disability and dependency status. I also grant permission for TRIO-SSS staff to access and gather information concerning my academic records, academic progress, class attendance, and allow collaboration with ILCC faculty and staff concerning all the above.

TRIO SSS may take photographs or video recordings of TRIO-SSS participants while involved in program activities for the use of program promotion, including social media.
Student Signature*

Clear
Electronic Signature Agreement: You agree your electronic signature is the legal equivalent of your manual signature on this application. You agree that your signature on this document is as valid as if you signed the document in writing.
Today's Date

MonthDayYear
Date
Should be Empty:

TRIO-SSS Student Application

Part 1: Personal Data

Part 2: Need

Part 3: Verification

Part 4: First Generation Student Verification

Part 5: Dependency and Financial Verification

Independent Student Status

Dependent Student Status

Part 6: Release of Information & Affidavit of Truth Statement