TRIO SSS STUDENT APPLICATION

The following information is being requested for the purpose of considering you for participation in the TRIO Student Support Services progam at Prairie State College. Participants must be at least a half-time student in need of academic support services, AND be able to meet at least one of the following criteria:
- Neither parent/guardian received a bachelor’s degree
- Eligible based on income level
- Documented disability
PRIORITY WILL BE GIVEN TO STUDENTS WHO INTEND TO TRANSFER AND COMPLETE A BACCALAUREATE DEGREE

All information submitted will be secured in compliance with the Family Educational Rights and Privacy Act.
Check the current semester of which you are completing this application:*

Spring 2024Summer 2024Fall 2024
Name*

First NameLast Name
MI
Student ID #*
Address*

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone*
Birth Date (ex: 04/01/2062)*

MonthDayYear
Date
Preferred Email*
example@example.com
Demographic Data:
Gender*

Male:FemaleNo responseOther
Are you a U.S. Citizen?*

YesNo
If not, are you a Permanent Resident?

YesNo
If so, what is your USCIS#
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Race (check all that apply)*

American Indian/Alaska NativeAsianWhiteBlack or African-AmericanNative Hawaiian or other Pacific
Have you ever participated in any other TRIO Program(s)?

Talent SearchUpward BoundStudent Support Services
Class Standing*

Freshman 0 – 29 hrsSophomore 30+hrs
Have you previously attended other colleges or universities?*

YesNo
If yes, where?
Have you earned*

High School DiplomaDual CreditGED
What Year was HS Diploma, Dual Credit, or GED completed?
Do you plan to attend:*

Full-time (12 or more credit hours/semesterPart-time (6-11 credit hours)
What is your college degree program? (Associate of Arts, Associate of Science, etc.)
Major?
Do you plan to transfer to a 4-year university?*

YesNoUnsure
If yes, do you know where you plan to transfer?
What is the highest level of education COMPLETED by your parents?
Mother/Birth or Adoptive/Legal Guardian*

Grade SchoolHigh School2-Year College4-Year Degree or HigherUnknown
Father/Birth or Adoptive/Legal Guardian*

Grade SchoolHigh School2-Year College4-Year Degree or HigherUnknown
If you/your family filed income taxes last year, what was your TAXABLE income(Use Parents’ taxes if dependent This is NOT Adjusted Gross Income. This information is on line 15 of prior year Form 1040.*

Less than $20,385$20,385 - $27,465$27,466 - $34,545$34,546 - $41,625$41,626 - $48,705$48,706 - $55,785$55,786 - $62,865$62,866 - $69,945more than $69,945DID NOT FILE
Number of people in the family?*
Are you, the student, a single parent?*

YesNo
Did you apply for financial aid for the current school year?*

YesNo
Have you received an award letter from the financial aid office?

YesNo
What is your dependency status according to Financial Aid? Note: This will be verified by PSC's Financial Aid Office*

DependentIndependent
What type of financial assistance are you receiving (Check all that apply)?

ScholarshipLoanPell GrantVeteran'sNo AssistanceOther
Would you like to report a documented disability that could affect your education? This information is voluntary and you are not required to answer this question. Any information provided will be kept confidential and used for this program only. Any refusal to provide information will not subject you to any adverse treatment. Any information provided will only be used for this program and for no other purpose. Note: Documentation of disability is required. Disability documentation for any PSC student is retained in the Access & Disability Services Office.

NoYes
What services have you received to accommodate this disability?
In which of the areas listed below do you need assistance (check all that apply)?*

Academic AdvisingPersonal CounselingTime ManagementTest Taking SkillsClass RegistrationCultural EnrichmentFinancial Aid ProceduresTransfer AssistancePeer MentoringSocial SkillsCareer ExplorationTutoringStudy SkillsChoosing a MajorBudget Planning
I certify that the information that I have provided on this SSS application is correct and complete. By signing this form, I authorize TRIO Student Support Services to obtain any and all information, and documentation necessary for processing and the ongoing evaluation of my academic pursuits. I also give my permission for the TRIO Student Support Services staff to share my information (including but not limited to IEP, 504, Test Scores, FAFSA) with other staff, faculty, and mentors if it will assist in my academic success.
WARNING: Falsifying information on this form is a federal offense, punishable by a fine, imprisonment, or both.
Student Signature*

Clear
Today's Date*

MonthDayYear
Date
*Parent/Guardian Signature:
*Parent Signature Required for Dependent Students

Clear
Today's Date

MonthDayYear
Date
ADA Compliance Statement
Prairie State College (PSC) is committed to providing reasonable accommodations for enrolled or admitted students with documented disabilities. The Access & Disability Services seeks to maintain academic standards while providing equal access and support services to students who are able to benefit from courses offered by the college, have the commitment to succeed, and have a documented disability.
Should be Empty:

Demographic Data:

*Parent/Guardian Signature:

ADA Compliance Statement