TRIO Application 2024-25

Southwestern Community College Instructional Center, Room 702 (2nd floor) 1501 W. Townline Street Creston, IA 50801

Date

Name

First NameMiddle NameLast Name

MaleFemale

Student ID

Please enter your local address below

Address

City, State & Zip

Birthdate

Date

Primary Phone Number

May we use your cell phone number to text you important information?

YesNo

Marital Status:

Number of dependent children

Former TRIO TS or Upward Bound member?

YesNo

U.S. Citizen:

YesNo

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

YesNo

High School Attended

High School Graduation Date

Degree earned

DiplomaGED

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

YesNo

College Degree(s) earned

NoneDiplomaAssociatesHigher Degree

Major

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 NativeAsian 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 AfricaWhite or Caucasian tracing your ancestry to Europe, Middle East, or North AmericaHawaiian 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?

YesNo

Have you completed your FAFSA application?

YesNo

Are you currently or will you receive a Pell Grant?

YesNoDon't know

Are you planning to earn a degree at SWCC?

YesNo

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

YesNo

What institution do you plan to transfer to?

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

YesNo

If you need accommodations for a disability, please contact SWCC's Coordinator of Disability Services at 641782-1458. If a disability qualifies you for TRIO services, students are required to provide documentation of the disability to TRIO-SSS unless documentation has been provided to the SWCC Disabilities Coordinator All documentation will be kept confidential. (optional)

Are you receiving services from Voc. Rehab?

YesNo

Do you have career goals?

YesNo

Please describe:

Dependent Student:

YesNo

You are a dependent student if you were born on or AFTER January 1, 2001, 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.

Independent Student:

YesNo

You are an independent student if you were born BEFORE January 1, 2001, 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 initial interview.

Student Signature

Date

Staff Signature

Date

SWCC is an Equal Opportunity Educational Institution and Employer. For information regarding the nondiscrimination policy at SWCC, please visit www.swcciowa.edu/nondiscrimination or contact the Equity/Title IX Coordinator. Phone: 641.782.1456 or 800.247.4023, ext. 456; Email: TitleIXCoordinator@swcciowa.edu

TRIO-Student Support Services is 100% federally funded for $325,051 by the U.S. Department of Ed.Updated 3/30/2023

Major you plan to pursue at SWCC?

High School Graduation Date

Is this a cell phone?

Type option 1Type option 2Type option 3Type option 4

Date