Southwestern Community College
Instructional Center, Room #213
1501 W. Townline Street
Creston, IA 50801
Please print and use a pen.
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name:
First Name
Middle Initial
Last Name
Student ID:
Male
Female
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Phone Number:
Format: (000) 000-0000.
Is this a cell phone?
Yes
No
May we use your cell phone number to text you important information?
Yes
No
Marital Status:
Single
Married
Divorced
Separated
Widowed
Number of dependent children:
Former TRIO TS or Upward Bound member?
Yes
No
U.S. Citizen:
Yes
No
If not, are you a permanent resident of the U.S.?
Yes
No
High School Attended:
Degree earned:
Diploma
GED
High School Graduation Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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.
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:
Do either of the parents/guardians that you lived with have a four-year Bachelor's degree?
Yes
No
Over
Back
Next
Have you completed your FAFSA application?
Yes
No
Are you currently or will you receive a Pell Grant?
Yes
No
Don't know
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 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.?
Yes
No
Yes
No
Please describe:
Dependent Student:
Yes
No
You are a dependent student if you were born on or AFTER January 1, 2003 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:
Yes
No
You are an independent student if you were born BEFORE January 1, 2003 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
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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. Updated 02/06/2026
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