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TRIO STUDENT SUPPORT SERVICES APPLICATION
Per the Family Educational Rights and Privacy Act, information in this application is confidential ‐ we will protect your sensitive personal data. PRINT clearly. Incomplete or penciled applications may be returned to you or rejected.
Name SSN
Street City/State Zip
Phone DOB Owens ID
Owens Email
In accordance with federal regulations, a student must meet one of the following criteria to be eligible for program services:
A first generation college student (neither parent has a Bachelor’s degree)Limited income (verified by an SSS staff member)Have a documented disability
If yes, have you registered with the OCC Office of Disability Services? Yes No
Demographic Data
(Note: the U.S. Department of Education will not recognize other designations outside of those listed below.)
Gender: Male Female Marital Status: Single Married Divorced Widowed
Citizenship Status: U.S. citizen Permanent Resident Other: ___________________
Race or Ethnicity (check all that apply): Black or African American Hispanic or Latino White AsianNative Hawaiian or other Pacific Islander American Indian or Alaska Native
Were you ever a member of any of the following Access Programs? NO YES: check which one(s) below:
Upward Bound Jumpstart EOC Other ______________________________
Academic Information
Major: ________________________________ Full Part‐TimeHigh School GPA (if less than 3 years after graduation): _________ What is your expected year of graduation from Owens? ________ Advisor: ______________________________________
What is your current Owens State Community College academic status? New student, regular admissionNew student, Falcon Express, Rocket ExpressTransfer studentGood standingWarningProbationMay Continue (previously dismissed or suspended from Owens)
Financial Eligibility
If you and/or your family filed income taxes last year, what was your combined TAXABLE INCOME? Note: It is
very important that you indicate TAXABLE income and not total income or adjusted gross income. The best source
for this information is your prior year Federal tax return. Taxable income is reported on: line 43 of form 1040; line 27
of 1040A; or line 6 of 1040EZ. The other option is to provide your Student Aid Report (SAR), from the FAFSA site.
I/my family did not have taxable income in the prior year $______ Prior year total taxable income (from tax return) _______ Number living in household
NOTE: If you are an independent student for financial aid purposes, please identify yourself as being one or more of the following: Have you completed an undergraduate degree? (Note: If so, you are not eligible to join SSS) Are you a veteran of the U.S. Armed Forces or currently serving on active duty in the U.S. Armed Forces for other than training or state (National Guard or Reserves) purposes? At any time since you turned age 13, were both your parents deceased, were you in foster care or were you a dependent or ward of the court? Has it been determined by a court in your state of legal residence that you are an emancipated minor or that you are in a legal guardianship? I hereby certify the information I have furnished regarding the size of my family and taxable income is true to the best of my knowledge and hereby grant permission Owens State Community College TRIO Student Support Services to have access to my official records in order to complete my application. (Your application will not be complete without signatures and dates.) I give Student Support Services (SSS) my permission to access my educational records and other materials necessary for participation in the SSS Program. Furthermore, I understand that all my records are kept confidential and in accordance with Owens State Community College and Federal Privacy Laws. I certify that the above information is complete and accurate to the best of my knowledge. However, I give permission for release of my data (name, photos, data related to awards and achievements) for purpose of awards, recognition and advertising. Permission to take my picture for recognition and advertising purposes: Yes No Please sign, date and return this form. If you are considered a dependent, as defined in the FAFSA, you must have your parent/guardian sign and date this form. Electronic signatures will not be accepted. Print student name: __________________________________________________________ Student Signature: ___________________________________________________________ Date: __________________ Print parent or guardian name (if claimed as dependent on tax forms): _____________________________________________ Parent or Guardian Signature: _________________________________________________ Date: _________________ Parent/Guardian email: _______________________________________________________
Please inform us of your needs and interests. (Check all that apply)
Areas of academic need:
Math Study Skills Career Development (choosing major/minor) Foreign Language Note Taking Course Selection Reading Organization Major/Minor requirements Writing Testing/Test Prep Academic Roadmap to Graduation English Proficiency Time Management General Education Requirements Computer Skills Improve GPA Transfer to a 4 year institution Preparation Research Skills Others _______________________
What other areas will you need assistance with? Personal budget Stress Management Applications Interviewing FAFSA Motivation Search Process Resume/Cover Letter Grants/Scholarships Test Anxiety Funding Job Searching Loans Understanding Diversity Goals/Decision‐Making Co‐op/Internship
Please list your personal goals and career objectives (example: what career do you want to do after you graduate?): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
Why are you interested in joining Owens TRIO Student Support Services? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
How did you hear about Owens TRIO Student Support Services? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
This application may be mailed, hand-delivered, faxed and/or scanned and e-mailed.
Return to: TRIO Student Support Services Attn: Erica Parish 120‐K College Hall PO Box 10,000
Toledo, OH 43699 E‐mail: [email protected]
(Please indicate “SSS Application” in the subject line) Phone: 567-661-2310 Fax: 567-661-2237