Trio Application

Name

First NameLast Name

Address

Street Address Line 2

CityState

Zip

Email

example@example.com

LoLA ID

Please select the race(s) with which you identify:

Are you Hispanic/Latino

Did you graduate from high school or complete the GED/HiSet?

What is your citizenship status?

Have you ever participated in the education Talent Search , Educational opportunity center, or Upward Bound program?

Who do you live with?

Number people in your immediate family? (parents, siblings, spouse, children)

Did your father earn a four year degree (bachelor's or higher)

Did your mother earn a four year degree (bachelor's or higher)

Do you have a documented disability? (ex. Learning: ADD, ADHS, Dyslexia; Neurological: Autism, Seizure; Mental Health: Anxiety, Depression, Bipolar; Physical: Mobility Impairment, Chronic Pain; Sensory; Blind or Low Vision, Deaf or Hard of Hearing; Chronic: Diabetes, Crohn's, Epilepsy)

Have you met with the RPCC's Office of Accessibility Services for accommodations?

Other

What is is major?

Are you currently working?

Do you plan to work while you are enrolled in classes

How many hours per week do work/ plan to work?

In what SSS services are you interested? (Please check all that apply)

Authorization: I authorize RPCC to access my academic records and FAFSA/financial aid information as needed to verify my eligibility for services.

Are you receiving financial assistance from any of the following? (Please check all that apply)

Student Income Verification- Check the amount below that best matches your household’s current taxable income:

I am interested in participating in the Student Support Services program to achieve my educational/vocational goals. I agree to participate in all recommended services and will keep all appointments until my goals are met. I further agree to complete the recommended assessment tools. I have read the foregoing in full and hereby certify that, to the best of my knowledge, all information contained herein is accurate. I permit the SSS program to secure my high school transcript/GED scores, ACT/ASSET scores, financial aid information, disability services information, and other needed academic/financial information from appropriate agencies (i.e. DHS, Rehab, Services, Single Parent Program, VA, etc to provide services. I agree to sign in and out electronically through a database program when appropriate.

The SSS Program at RPCC is funded in total (100%) by federal grant funding from the U.S. Department of Education, with an annual budget of $226,600. For questions and other information, please call (225) 743-8514

TRiO Student Support Services Application