TRIO Student Support Services

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TRIO Student Support Services - Application

First Name *

Last Name *

Student ID Number

Date of Birth (MM / DD / YYYY) *

Age *

Sex Identified at Birth *

Male

Female

Are you Hispanic or Latino? *

Yes

How do you describe your racial/ethnic background? *

American Indian or Alaskan Native

Black or African American

Native Hawaiian or Pacific Islander

Asian

White

Are you a US Citizen or Permanent Resident *

If you are Permanent Resident please enter your Permanent Resident number

Mobile Number *

Home Number

Email Address *

Do you already have a Bachelor's Degree?

Yes

Clear selection

Prior to Simpson were you at a different College/University or High School? *

Different College or University

High School

Enter the Month and Year you first started (or will start) at Simpson? *

Program *

Traditional Undergraduate

Degree Completion

Pre-Nursing

Nursing Program

Other:

What year are you currently in at school? *

Freshman (Never Attended College Before)

Freshman (Have completed some college credits)

Sophomore (2nd year of college)

Junior (3rd year of college)

Senior (4th year of college)

Senior (5th year of college)

Major *

Nursing Students Only: Please enter your semester

Athletics

Have you been part of a TRIO program before? If so, which ones? *

Talent Search

Upward Bound

Upward Bound Math-Science

Veterans Upward Bound

EOPS

AVID

Educational Talent Search (ETS)

Student Support Services

N/A

Other:

Required

Pleases indicate the highest level of education completed by the natural or adoptive parent(s) you lived with prior to age 18

Parent 1 *

Parent 2 *

Have you registered for disability accommodations with the Academic Success Center? *

Yes

Please select all that apply to you

I have children or other dependents

I was in foster care or a dependent/ward of the court

Someone other than my parent/stepparent has legal guardianship over me.

I'm currently on active duty or a veteran of the U.S. armed forces

Both of my parents passed away before I turned 24 years old

I'm an unaccompanied youth that is/was homeless or at risk of being homeless

None of these apply to me

Other:

College Preparedness (Select all that apply)

I have not taken college level courses and/or I did not score high grades in these classes

I need academic support to raise my grades

I do not feel prepared for college level course work

I've had low grades or failing grades

I've been out of school for 5 or more years

I have limited English Proficiency

Other:

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services program under the Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services program. The principle purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties.• By signing this application, I certify that all information provided above is true and accurate to the best of myknowledge.• I understand that all information on this application, as well as that released from the school, will be held in strict confidence by the TRIO Student Support Services program staff.• I authorize the release of academic records (e.g. copies of school transcripts, test scores) to Simpson's TRIO Student Support Services program in order to assess need/eligibility for program services, discern academic progress, evaluate the effectiveness of program activities, and fulfill program reporting requirements.• I consent to the disclosure of any personally identifiable information as defined by FERPA of my education records to Simpson's TRIO Student Support Services program staff for the purpose of confirmation of the student’s postsecondary enrollment status as reported on the National Student Clearinghouse Student Tracker. This authorization will remain in effect for six years following admission into Simpson's TRIO SSS program.• I authorize the release and exchange of student financial aid information from colleges and the federal government to the TRIO Student Support Services program.• I authorize the TRIO Student Support Services program to share and discuss information with school personnel in support of my student’s academic success.• I also give permission for the TRIO Student Support Services program to take photographs for identification purposes and during activities, and grant permission to use the student’s name, comments, and/or photos/videos for educational and/or promotional purposes.• I understand that this authorization will remain in effect while the student is enrolled in Simpson's TRIOStudent Support Services program or until written notice is provided to revoke the authorization.

Electronic Signature - Enter your full name below - This will complete your application to the TRIO Student Support Services. *

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