IMPACT/TRiO Application
Student Information
Student ID:
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Personal Email:
example@example.com
Cowley Email:
example@cowley.edu
Gender
Please Select
Male
Female
Nonbinary or another gender
No response/Unknown
Citizenship Status:
Please Select
U.S. Citizen
Permanent Resident
Refugee
Not a Citizen
Ethnicity (Please Select All That Apply):
American Indian/Alaskan
Black/African American
Caucasian/White
Asian
Hispanic/Latino
Hawaiian/Pacific Islander
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IMPACT/TRIO Program Questions
First generation college student means (1) A student neither of whose natural or adoptive parents received a baccalaureate degree; (2) A student who, prior to the age of 18, regularly resided with and received support from only one parent and whose supporting parent did not receive a baccalaureate degree; or (3) An individual who, prior to the age of 18, did not regularly reside with or receive support from a natural or an adoptive parent.
Has your mother received/earned a bachelors degree (completed all 4 years):
Yes
No
Don't Know
Has your father received/earned a bachelors degree (completed all 4 years):
Yes
No
Don't Know
Do you currently receive academic accommodations through Cowley's Accessibility Coordinator, or do you have a 504 Plan or IEP that could qualify you for disability-related services?
What services, if any, have you received in the past to accommodate your documented disability?
**Note: Documentation of your disability must be given to Cowley IMPACT. This information is retained in confidential files and only used by the IMPACT or ADA offices.
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Prior School Information
Highschool Attended:
City and State:
Did you graduate?
Yes
No
If YES, date graduated (MONTH/YEAR):
If NO, what is your anticipated date (MONTH/YEAR):
Did you receive your GED?
Yes
No
N/A
If YES, date you received your GED (MONTH/YEAR):
Did you take the ACT?:
Yes
No
N/A
If YES, what was your ACT Composite Score?
Have you attended any other college/academies/tech schools after highschool?
Yes
No
If you answered YES to the previous question, please provide School Name, Year Started, and Year Ended
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Student or Future Student Status
Hours Enrolled
Full Time (12+ hours per semester)
Part Time (Less than 12 hours per semester)
Campus Location Preference
Arkansas City
Mulvane
Winfield
Wellington
Wichita Downtown
Online Student
When was or will be your first semester at Cowley?
Please list (FALL/SPRING/SUMMER) and the YEAR
Have you taken any Cowley College Classes BEFORE applying to our program?
Yes
No
Declared or Preferred Major
Declared Career Choice
What's the highest degree you would like to receive?
Associate (2 years)
Bachelors (4 years)
Masters (4 years + 2 years grad school)
Doctoral (anything above a masters)
Do you plan to continue your education beyond Cowley? If yes, please list your top 3 transfer schools?
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Additional Questions
What obstacles would most likely prevent you from completing your academic goals?
Poor study habits
Lack of money
Taking the wrong classes
Always feeling tired
Always worrying
Being shy
Easily distracted
Bad grades
Taking things too seriously
Problems at home
Trouble sleeping
Afraid to speak up in class
Feeling depressed or sad
Dealing with bill collectors
Family medical problems
Separation or divorce
No friends at Cowley
Recurring health concerns
Alcohol and/or drug issues
No support from family
Friends
How did you hear about the IMPACT program?
Explain the reason(s) why you are applying to the IMPACT/TRiO program?
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Certification, Authorization, and Media Consent
I certify that the information I have provided on this application is, to the best of my knowledge, complete and accurate. Furthermore, I understand that by applying for the IMPACT/TRiO program, I authorize the program staff to obtain records or pertinent data necessary for this program. I acknowledge that this program is a federal grant program, and some of our records may be released to the United States Department of Education or TRiO Programs. Additionally, I grant the IMPACT/TRiO staff permission to communicate verbally or otherwise with staff, faculty, and/or off-campus professionals on my behalf. I agree that if I am accepted into the IMPACT/TRiO program, the staff may include my name and/or picture in publications, including but not limited to the IMPACT websites. The websites are used to highlight student accomplishments and participation in campus and IMPACT/TRiO activities.
By typing my name, I acknowledge and agree to the terms outlined above and confirm that I am electronically signing this application.
Submit
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