TRIO-SSS Application

Southwestern Community College Instructional Center, Room 702 (2nd floor)

Date

First MI Last

Male Female

Student ID

Address

City, State & Zip

Birthdate

Date

Primary Phone Number

YesNo Is this a cell phone? YesNo Is this a cell phone? YesNo May we use your cell phone number to text you important information? Type option 7

Primary Phone Number

YesNo Is this a cell phone? YesNo Is this a cell phone? YesNo May we use your cell phone number to text you important information? Type option 7

Primary Phone Number

Secondary Phone Number

Marital Status

Single Married Divorced Separated Widowed

Number of dependent children

Former TRIO ETS or Upward Bound member?

Yes No

If not, are you a permanent resident of the U.S.?

Yes No Yes No

High School Attended

Degree earned

Diploma GED

Have you attended any college (including SWCC) before now?

Yes No

College Degree(s) earned

None Diploma Associates Higher Degree

Major you plan to pursue at SWCC?

What race(s) do you most closely identify with?

Native or indigenous tracing your ancestry to South America. North America or Central America., including American Indian and Alaskan Native Asian tracing your ancestry to Southeast, East, Indian subcontinent, Cambodia, China, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, Vietnam, etc.

Asian tracing your ancestry to Southeast, East, Indian subcontinent, Cambodia, China, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, Vietnam, etc.

Black, African, or African American tracing your ancestry to Africa

White or Caucasian tracing your ancestry to Europe, Middle East, or North America Hawaiian or Pacific Islander tracing your ancestry to native peoples of Hawaii, Guam, Samoa, or other Pacific Islands

Do you identify as

Hispanic/Latino ? Neither

Language spoken at home

Have either of your parents/guardians received a four-year Bachelor's degree?

Yes

No

Over

Have you completed your FAFSA application?

Yes No

Have you completed your FAFSA application?

YesNo Don't know Are you currently or will you receive a Pell Grant?

Are you currently or will you receive a Pell Grant?

Yes No

Are you a dependent/spouse of a Veteran?

Are you planning to earn a degree at SWCC?

Yes No

Do you plan to transfer to a 4-year institution to earn a Bachelor's degree?

Yes No

What institution do you plan to transfer to?

Do you have a documented physical, mental, or learning disability?

Yes No

If you need accommodations for a disability, please contact SWCC's Coordinator of Disability Services at (641)782-1458. If a disability qualifies you for TRIO services, students are required to provide documenta tion of the disability to TRIO-SSS (unless documentation has been provided to the SWCC Disabilities Coor dinator All documentation will be kept confidential. (optional)

Are you receiving services from Voc. Rehab.?

Yes No

Do you have career goals?

Yes Please describe: No

Please describe

Distance traveling to college one way: (students living on campus should select "local")

Local 10-25 miles 26-35 miles 36-50 miles 51 plus

Independent Student

YesNo Dependent Student: Yes No You are a dependent student if you were born on or AFTER January 1, 1999 are single, have no children, or you are not a Veteran or on active duty in the Armed Forces, or as otherwise defined by FAFSA.

You are an independent student if you were born BEFORE January 1, 1999, are married, have a child, or you are a Veteran or on active duty in the Armed Forces, or as otherwise defined by FAFSA.

I understand the TRIO-Student Support Services program will use the data provided and it will be kept confidential. I release the following information to the SSS staff: high school transcripts, SAT/ACT scores, award notices, photo, FAFSA information and any other academic records pertaining to my enrollment.

*Completion of this application does not automatically make you a TRIO member. Please make an appointment for an initialinterview.

Student Signature

Clear

Date

Staff Signature

Clear

Date

Equal Opportunity Educator and Employer. For more information regarding the nondiscrimination policy at Southwestern Community College, please contact: Educational Equity Coordinator: (641) 782-1456 or 1-800-247-4023, ext. 456. Updated 5/4/2021 TRIO-Student Support Services is 100% federally funded for $312,549 by the U.S. Department of Ed.