TRIO SSS Application

Application & Interest Form

We are excited that you have chosen to apply for TRIO SSS at LSC-Montgomery!
In order to be considered, you must be a U.S. citizen or permanent resident, have an academic need, and must be at least one of the following:
- First Generation College Student (neither parent has a four-year degree)
- Low Income Student (you may receive Pell or other forms of financial aid)
- Individual with Documented Disability
Please complete this form in its entirety. You may be asked to submit additional supporting documentation. The TRIO staff will contact you directly to review those forms. And lastly, don't forget to sign and date the application!

TRIO SSS is a 100% federally funded program under the U.S. Department of Education.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Student ID Number*
Lone Star College Student ID Number
Social Security Number*
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Tell Us About Yourself
Ethnicity (choose all that apply)*

African American (Black)American IndianAsianCaucasian (White)Hispanic or Latino/aMulti-Ethnic (more than one)Pacific IslanderOther
Gender*

MaleFemalePrefer not to say
Marital Status*

MarriedDivorced/SeparatedSingle
Referral: How did you hear about the TRIO SSS program?
Program Eligibility

In order to be considered for the TRIO Student Support Services program, you must be a U.S. citizen or Permanent Resident, have an academic need, and must be at least one of the following: First Generation College Student (neither parent has a four-year degree), Low Income Student (you may receive Pell or other forms of financial aid), or an Individual with Documented Disability.
Have either of your parents (guardians) graduated from a college with a four-year degree?*

YesNo
Citizenship*

U.S. CitizenPermanent ResidentOther
Are you receiving Financial Aid this semester?*

YesNo
Do you have a documented disability?*

YesNo
If you answered yes to the question(s) listed above, please submit the ADA form to the TRIO SSS program office located in Building C, Room 221C
Were you ever a ward of the court?*

YesNo
Were you ever in foster care?*

YesNo
Academic Information
Do you have a—*

High School DiplomaGED
Have you ever attended Lone Star College before?*

YesNo
Are you currently enrolled in any Developmental/Support classes?*

YesNo
Have you ever had to repeat any of the Developmental classes?

YesNo
Are you currently receiving services from another TRIO or federally or state funded program (ex. CLASS or SSI)?*

YesNo
Please check any of the following statements that apply to you.*

Completed at least one semester of college.Displaced worker (previously employed but lost job).Not attended any school for 5 or more years.Majoring in science, technology, engineering or math (STEM).Not applicable
Enrollment Status*

Full Time (12 or more credit hours)Part Time (6 or less credit hours)Day ClassesEvening ClassesOther
At which campus are most of your classes located?*

LSC-CyFairLSC-Houston NorthLSC-KingwoodLSC-MontgomeryLSC-North HarrisLSC-University ParkLSC-Online
What is your educational goal? Check all that apply.*

Associate's Degree (AA, AS, AAS)Certificate ProgramTransfer onlyGraduate and transfer to a four-year college/university
Major area of interest*
Have you attended another school/college/university before coming to LSC-Montgomery?*

YesNo
If you are planning to graduate and transfer to a four-year college or university, please list the top three schools that you are considering.
Employment Information
Please briefly state your academic and career goals.*
Do you work?*

YesNo
Student Certification and Release

I, the above named student, certify that the information I have provided on this application is complete and correct. I authorize the TRIO SSS staff to track my academic progress through the National School Clearinghouse. I give my permission for the TRIO SSS staff to access and verify any information on this document. The federal government requires that TRIO SSS have on file documentation of taxable income, such as federal tax forms or the Student Aid Report from FAFSA, for all students admitted to the program.
Signature*

Clear
Date of Birth*

MonthDayYear
Date
Date

MonthDayYear
Date
Should be Empty:

Application & Interest Form

In order to be considered, you must be a U.S. citizen or permanent resident, have an academic need, and must be at least one of the following:

Tell Us About Yourself

Program Eligibility

Academic Information

Employment Information

Student Certification and Release