TRIO SSS Full Application 1. Student InformationNOTE: All Fields are required. If you DO NOT have an answer please use N/A (not applicable)Name* First Last Student ID*If you DO NOT have a Student ID, answer with Not Available. Email* Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Is it ok to text?* Yes No Sex* Male Female High school from which you graduated (or GED) U.S. Citizen* Yes No Race* White Black or African American American Indian or Alaska Native Native Hawaiian or Pacific Islander Other Ethnicity: Are you Hispamic or Latino?* Yes No If not, are you a resident alien? Yes No Do you have a Documented Disability?* Yes No Previously applied for ASU Mid-South Disability Services?* Yes No Classifications* Freshman (0-29 credit hrs) Sophomore (30+ credit hrs) Date you last attended high school or college (Month/Year):* College Major:*If you DO NOT have an answer please type Not Available. Current college GPA, high school GPA, or GED score:*If you DO NOT have an answer please type Not Available. How did you find out about TRiO? Have you ever participated in Talent Search, Educational Opportunity Center, or Upward Bound Project?* Yes No 2. Parent InformationDoes your mother have a four year degree?* Yes No Does your father have a four year degree?* Yes No Which parent did you regularly reside with and receive support from until turning 18 years old?* Mother Father Both Neither 3. Dependent InformationHave you already graduated from college with a Bachelor’s Degree?* Yes No Are you married?* Yes No Do you have children who receive more than half of their support from you?* Yes No Do you have dependents (not your children or spouse) who live with and receive more than half their support from you?* Yes No Are both your parents deceased, or were you a ward/dependent of the court or in foster care (until age 18)?* Yes No Are you a veteran of the U.S. Armed Forces or currently serving on active duty in U.S. Armed Forces?* Yes No Are you an emancipated minor, in legal guardianship, an unaccompanied homeless youth, or at risk of being homeless?* Yes No In order to determine eligibility you will need to provide your parent’s income information in STEP 4. You can do this in several ways: 1. Have a parent sign the form and enter income information 2. Attach a signed copy of your parents’ most recent income tax form4. Parent's Income InformationWhat is the total number of persons in your family?* Please select one of the following:* I attest that my family had no taxable income for the last calendar year. I attest that my family did not file a federal income tax return for the last calendar year. My family’s taxable income from the last calendar year was: My Family's Income was or Total Income* Note: Income tax information can be found on the federal income tax return you filed for the last calendar year. • Form 1040 Line 37 • Form 1040A Line 21 • Form 1040EZ Line 45. Assistance & ObjectivesWhat type of assistance do you need to be a successful college student?*(Check all that apply) Select All Campus Visitations Career Coaching Computer Assistance Coping with Stress Cultural Activities Financial Aid Coaching Financial Literacy Information Workshops Personal Coaching Study Skills/Workshops Transfer Coaching Tutoring What are your educational objectives for the next two years?* What are your educational objectives for the next four years?* Which, if any, financial aid are you receiving?*Check all that apply Select All Pell Voc. Rehab Private Scholarship AR Academic Challenge Work Study Other 6. Likelihood of SucessAs of today, how committed are you to reaching your goals at ASU Mid-South?* Very Committed Somewhat Committed Committed Not Committed Don't Know Do you plan to re-enroll next semester?* Yes No 7. Read, Sign & DateMy signature below certifies that the above information is correct and that I have a desire to pursue a program of postsecondary education (HEA, SEC 402F(a)(1)) and am in need of academic support to successfully pursue a postsecondary education. I grant the TRIO Programs permission to send for/receive copies of transcripts, financial aid awards, test scores, and other relevant information necessary for participation in the program and allow state and federal agencies permission to release income information.Student/Participant's Signature*Date* MM slash DD slash YYYY Parent's Signature(Parent’s signature or signed tax return is required if applicant is less than 24 years old and answered NO to all of the questions in STEP 3)Date* MM slash DD slash YYYY TRIO SSS - IEPDivision GoalsEducation Goals* AA AAS AAT AS Select all that apply* No Yes 12 hours or more 7-11 hours 6 hours 6 hours or less Expected date of Graduation* Fall CoursesSpring CoursesSummer Courses CAREER PLANNING Employed* Yes No LASSI (Date Taken):* 123Test.com (Career/Tests) (Date Taken):* Counseling Date:* Virtual Career Center (Date Registered):* TRANSFER COUNSELING Counseling Date:* Intended Transfer College* Transfer Academic Program:* PELL Finacial Aid Counseling Date:* 21-22 FAFSA Completed?* Yes No Date Taken?* MM slash DD slash YYYY Receipt of Financial Aid (Amount & Date) Fall Semester* Spring Semester* Summer Semester* Disability* Yes No Date Documented with College:* Date Documented with AR Voc. Rehab:* Date Documented with College* Benchmarks:Must complete these two sectionsFallSpringParticipant will select at least three (3) events per semester to attend from TRiO SSS Calendar:FallSpringCareer Pathways Participant* Yes No Student Signature*Date* MM slash DD slash YYYY Coach SignatureDate* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
