TRiO SSS Application

TRiO SSS Application

Madisonville Community College
Name*

First NameMiddle InitialLast Name
Student ID *
SECTION 1: PERSONAL INFORMATION
Preferred Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Pronouns
Are you Hispanic or Latino?*

NoYes
Race:*

American Indian/Alaskan NativeAsianBlack / African AmericanNative Hawaiian/Other Pacific IslanderWhiteMore than 1 Race
Best Phone*

Area CodePhone Number
E-mail Address*
Please use KCTCS email address: Astudent0001@kctcs.edu
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is your preferred type of communication? (Check all that apply)*

EmailTextPhoneSocial MediaOther
SECTION 2: ELIGIBILITY INFORMATION
Are you either a US citizen or a permanent resident of the US? *

YesNo
Do you have a documented physical and/or learning disability? *

YesNo
Are you registered with the MCC Accessibility Services office?*

YesNo
What is the highest level of education that your mother/guardian received?*

Middle SchoolHigh School2 year college degree (Associate)4 year college degree (Bachelors)
What is the highest level of education that your father/guardian received?*

Middle SchoolHigh School2 year college degree (Associate)4 year college degree (Bachelors)
According to Federal Financial Aid, you are financially independent if you are any of the following: 1) 24 years old as of January 1 of the academic year; 2) married; 3) have a legal dependent; 4) a veteran of the US Armed Forces; or 5) orphan or ward of the court (or was until age 18).
Are you an independent student per the above definition?*

YesNo
*If no, please utilize income information of your parent/guardian for the following information.
How many people live in your household and were claimed on taxes?*
Please choose the line that reflects your most recent taxable income (Line 15, Form 1040):*

Below $22,590$22,591 - $30,659$30,660 - $38,729$38,730 - $46,799$46,800 - $54,869$54,870 - $62,939$62,940 - $71,009$71,010 - $79,079$79,080 and aboveMy family DID NOT file income taxes.
If you are a dependent student, was taxable income verified by your parent/guardian?*

YesNo
SECTION 3: OTHER INFORMATION
Are you a first time freshmen (not including dual credit)?*

YesNo
If no, how long has it been since you attended a college?*
Have you taken dual credit or early college courses through your high school?*

YesNo
Have you filed your FAFSA (financial aid)? *

YesNo
If no, do you desire FAFSA assistance?*

YesNo
Are you planning to transfer after MCC? *

YesNo
What 4-year colleges are you considering / interested in attending?*
Please indicate which educational programs that you previously participated in:*

TRIO Talent SearchTRIO Upward BoundEOCGear UpTRIO SSS (at another college/university)N/A

Do any of the following academic needs apply to you:*

	Yes	No	N/A
If recently graduated, low high school grades (GPA below 2.0)
Low admission test scores (ACT lower than 20; low TABE scores; or low KYOTE scores)
Enrolled in one of the following courses: MAT 61, MAT 100, ENG 100, RDG 20, or RDG 100
GED
If not your first semester, college GPA is 2.5 or below
If not your first semester, failing grades in any college courses
Out of high school or college for 5 years or more
Limited English proficiency
Unsure of major in college or career goals
Lack of academic preparedness for college level work
My family supports my decision to attend college
I have family or friends I can go to when I need help academically

In your own words, explain why you want to be a participant in TRiO SSS? (ie. tutoring, grant aid, extra assistance, community, etc.)*
RELEASE OF INFORMATION / AFFIDAVIT OF TRUTH

(a) I give permission for Student Support Services personnel to access my MCC academic and financial aid records for the purpose of verifying project eligibility, potentially awarding grant aid, assisting me academically and/or for transfer purposes. I also grant the MCC Accessibility Office permission to release information to the SSS program for the purpose of eligibility if needed.

(b) I agree to actively participate in the Student Support Services project as outlined by my SSS Advisor. Failure to do so may result in me being dropped from the program.

(c) I authorize the use of my name and photos, videos, or interviews for publication or promotional purposes.

(d) I verify my full agreement and understanding of this application. I certify that the information provided is true and complete to the best of my knowledge.
Signature*

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