TRIO Application 2025-2026

TRIO
Southwestern Community College Instructional Center, Room #213 1501 W. Townline Street Creston, IA 50801
Date

MonthDayYear
Date
First
MI
Last
Student ID
Address
City State Zip
MaleFemale
Birthdate

MonthDayYear
Date
Primary Phone Number
Is this a cell phone?

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

YesNo
Marital Status:

SingleMarriedDivorcedSeparatedWidowed option 5
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

MonthDayYear
Date
Degree earned:

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

YesNo
College Degree (s) earned:

NoneDiplomaAssociatesHigher 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 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
Do either of the parents/guardians that you lived with have a four-year Bachelor's degree?

YesNo
Over
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 earn 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 (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.?

YesNo
Do you have career goals?

Type option 1Type option 2
Please describe:
Dependent Student:

YesNo
You are a dependent student if you were born on or AFTER January 1, 2002 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, 2002 are married, have a child, or you are a Veteran or on active duty in the Armed Forces, or as otherwise defined by FAFSA.
Student Signature

Clear
Date

MonthDayYear
Date
Staff Signature

Clear
Date

MonthDayYear
Date
If you have questions or complaints related to compliance with this policy, please contact: Lana Bartmess, Director of Human Resources/Equity/Title IX Coordinator (faculty or staff), Southwestern Community College, 1501 W. Townline St., Creston, IA, 50801, phone: 641.782.1456, or email: TitleIXCoordinator@swcciowa.edu; Kim Bishop, Dean of Students/Deputy Title IX Coordinator (students), Southwestern Community College, 1501 W. Townline St., Creston, IA, 50801, phone: 641.782.1413; or email: TitleIXCoordinator@swcciowa.edu; or the Director of the Office for Civil Rights, U.S. Department of Education, Cesar E. Chavez Memorial Building, 1244 Speer Boulevard, Suite 310, Denver, CO, 80204-3582, phone: 303.844.5695, fax: 303.844.4303, TDD: 800.877.8339, or email: OCR.Denver@ed.gov.

TRIO-Student Support Services is 100% federally funded for $325,051 by the U.S. Department of Ed.
Should be Empty: