Program Application
Thank you for your interest in the Illinois College TRIO Student Support Services Program. To apply, please fill out and submit the short online form below. You will receive a confirmation email of your application once you submit.
Full Name (include first, middle and last name):
*
First Name
Middle Name
Last Name
Preferred Name:
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IC Student ID #:
*
Date of Birth (mm/dd/yyyy):
*
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address:
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example@example.com
Phone Number:
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Format: (000) 000-0000.
Marital Status:
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Single
Married
Divorced
Widowed
Sex:
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Female
Male
Gender:
Please select one or more from the groups below:
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Black / African American
White / Caucasian
Asian
American Indian / Alaska Native
Native Hawaiian / Other Pacific Islander
Hispanic
Are you Hispanic/Latino?
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Yes
No
Are you a U.S. Citizen or permanent resident?
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Yes
No
Have you previously participated in a TRIO program?
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Yes
No
Please list the Title of the Program and Date(s) of Attendance:
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Please select one of the following programs that you participated in:
*
Please Select
Talent Search
Upward Bound
EOC
SSS
Does your mother/parent/guardian have a 4-year college degree?
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Yes
No
I don't know
Does your father/parent/guardian have a 4-year college degree?
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Yes
No
I don't know
If you did not live with a parent or guardian while attending high school, did the person you lived with have a 4-year college degree?
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Yes
No
I don't know
N/A
Are you receiving Financial Aid?
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Yes
No
I don't know
If you are NOT receiving Financial Aid, have you applied?
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Yes
No
I don't know
Are you Pell Grant eligible?
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Yes
No
I don't know
Do you have a documented disability?
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Yes
No
I don't know
Did you have an IEP or 504 plan in high school?
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Yes
No
I don't know
If you have a disability, have you contacted the Disability Services Coordinator?
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Yes
No
I don't know
N/A
Please read and check each box to indicate you understand these authorizations.
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I certify that the information I have provided here is true and correct to the best of my knowledge. I hereby authorize the TRIO staff to secure financial, personal and academic information necessary to verify my eligibility and provide the best possible services. All information will be kept confidential in accordance with the Federal Educational Rights & Privacy Act (FERPA) of 1974.
I hereby authorize the use of my photograph and name in any and all CAE/TRIO publications, examples include but are not limited to: the TRIO SSS website, program newsletters, bulletin boards and displays, campus-wide e-mail notices, and CAE social media sites.
Electronic Signature (please use your finger or mouse to sign in box):
*
Date & Time Signed
Submit
Should be Empty: