FRC TRiO SSS Application

Feather River College
TRiO / Student Support Services Application

If you have any questions, please contact the program director, Michelle Petroelje, at (530)283-0202 Ext 316 or mpetroelje@frc.edu
STEP 1 – Personal Data
Name*

First NameMiddle InitialLast Name
Street Address*
City, State, and Zip Code*
What is your home phone number?*
What is your cell phone number*
Can we please text you?*

YesNo
What is your personal e- mail address?*
example@example.com
What is the best way to contact you?*

EmailCallText
What is your student ID number?*
What is your birth date?*

MonthDayYear
Date
Are you a United States citizen or permanent resident with a Green Card?*

YesNo
What was your sex assigned at birth?*

FemaleMale
STEP 2 – Ethnic Background
Do you identify as Hispanic or Latino?*

YesNo
What is your ethnicity? Mark all that apply. (Please select at least one)*

American Indian/Alaskan NativeNative Hawaiian or Other Pacific IslanderAsianWhite/CaucasianBlack or African American
STEP 3 – Parental Information
Highest grade completed by mother?*

ElementaryHigh SchoolSome CollegeReceived 4-yr degree
Highest grade completed by father?*

ElementaryHigh SchoolSome CollegeReceived 4-yr degree
Which parent did you regularly reside with and receive support from during your childhood (i.e.: until you were 18 years old)?*

BothMotherFather
STEP 4 – Financial Information
Marital Status:*

SingleMarriedDivorced/separated
How many people live in your household?*
Are you receiving Financial Aid at Feather River College? *

YesNo
Do you receive the PELL Grant? *

YesNo
STEP 5 – Background Information
Are you married?*

YesNo
Do you have children?*

YesNo
Are you a U.S. Armed Forces veteran?*

YesNo
Are you serving on active duty in the US Armed forces?*

YesNo
Are/were you an orphan, in foster care, or a ward of the court?*

YesNo
Are/were you an emancipated minor or did you have a court-appointed legal guardian?*

YesNo
Do you have a diagnosed disability? (Physical, learning, and/or psychological)*

YesNo
If you indicated that you have a diagnosed disability above, have you registered with the DSPS office?

YesNo
STEP 6 – Services You May Need (Check ALL that apply)
Tutoring Assistance:*

MathEnglish/writingSciencesHistoryPolitical ScienceBusinessOther
Counseling/Advising:*

AcademicTransfer/admissionFinancial aidCareerPersonal
Academic Challenges:*

Study skillsTime managementFinancialOrganizational skillsStress/worryingPersonal/living environment issuesLack of support networkUnclear objectives/goals
STEP 7 – Educational Information
Are you currently a high school student? (NOTE: TRiO SSS cannot serve high school students)*

YesNo
Did you graduate from high school? (NOTE: TRiO SSS cannot serve students who haven't completed high school or earned a GED)*

YesNo
What is the last high school you attended?*
What was your high school GPA?*
Did you earn a diploma or GED?*

DiplomaGED
Do you plan to earn an associate’s degree at FRC?*

YesNo
Do you plan on transferring to a 4-year university?*

YesNo
If planning to transfer, which four-year college(s)/universitie(s) do you intend to apply/transfer to?
What is your current major?*
Please list any college(s) you have previously attended.
Please list any degrees/certificates you currently possess.
STEP 8 – Other Programs
Do you participate in another a program on campus? (Check all that apply)

FootballVolleyballCross Country/TrackMen’s SoccerWomen's SoccerSoftballBaseballMen’s BasketballWomen’s BasketballMen’s RodeoWomen’s RodeoOutdoor Recreation LeadershipEOPSCARE
STEP 9 – Acknowledgement
Please read the following statement and then sign and date below it. If you (the student) are under 18, your parent or legal guardian must also read the following statement and then sign and date below.

By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of the student’s official academic records to the TRiO/SSS program, understanding that the information in these records will be used only to assess the student’s need for program services, discern the student’s educational progress, evaluate the effectiveness of program activities, communicate with the student, and fulfill program-reporting requirements.
Please Draw Your Signature*

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Please Draw Your Signature*

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What is today's date?*

MonthDayYear
Date
Please Verify All Information on This Form is Accurate*
Should be Empty:

Feather River College

TRiO / Student Support Services Application

STEP 1 – Personal Data

STEP 2 – Ethnic Background

STEP 3 – Parental Information

STEP 4 – Financial Information

STEP 5 – Background Information

STEP 6 – Services You May Need (Check ALL that apply)

STEP 7 – Educational Information

STEP 8 – Other Programs

STEP 9 – Acknowledgement