Thank you for your interest in our Student Support Services program! Please complete this application as thoroughly as possible. You cannot save and restart this application. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application. If you have any questions, please call our office at (708) 456-0300 EXT 3484.

Note: Eligible students must be working towards completion of a certificate and/or first associate degree.

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PERSONAL INFORMATION

Last Name *

First Name *

Middle Name

Chosen Name *

Date of Birth *

Colleague ID Number (7 digit #)

Home Address *

Apartment #

City *

State *

Zip Code *

Phone # (no dashes or spaces) *

Preferred Email Address *

Residency *

Resident ID#

Gender *

Chosen Pronouns:

She/Her/Hers

He/Him/His

They/Them/Theirs

Ze/Zie/Hir

Primary Language *

Race/Ethnicity:

Please check all that apply:

HIspanic/Latino

American Indian/Alaska Native

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

White

Veteran

How did you find out about the SSS Program?

Other

Have you ever been a TRIO participant?

*TRIO programs include Upward Bound, Talent Search, Student Support Services and Educational Opportunity Center.

If yes, list program & school:

What is your major or academic interest?

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Eligibility Criteria: The following information is used to determine eligibility for SSS. Please read carefully! Failure to complete the following information may significantly delay review of your application. ALL SECTIONS MUST BE COMPLETED.

STUDENT DEPENDENCY INFORMATION

Note: Please skip this section if you are 24 years or older.

CHECK ALL THAT APPLY:

Are you married?

Do you have children?

Have you ever been a ward of the court, in foster care or an emancipated minor?

Serving active duty in the armed forces?

Active duty U.S. veteranl released under any condition other than dishonorably?

Are you under 18 years old with no parents or guardians?

Are you homeless or at risk?

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INCOME STATUS

Number of People in Household

Family's Taxable Income

Tax Year

Note: Taxable income can be found on the federal income tax form: IRS Form 1040. Tax year 2019.

Have you applied for financial aid?

Parent signature is required if student is dependent or under the age of 24.

Please select a signature verification type.

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FIRST GENERATION STATUS

Note: Please check the highest level of education completed for each parent/guardian.

Parent One

Parent Two

Guardian

Do you reside with:

If other, please specify:

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LEARNING OR PHYSICAL CHALLENGES (MAY ALSO BE REFERRED TO AS A DISABILITY)

You may apply for SSS if you have a medical, physical, sensory, cognitive or brain-related issue. However, you must also submit a detailed summary about the nature of the issue, written by an appropriate type of expert, to the Center for Access and Accommodative Services (CAAS) office in order to qualify under this criteria.

For more information, contact CAAS at (708) 456-0300, Ext 3854 or 3917.

Do you have a diagnosed learning or physical challenge?

Have you provided required documentation to CAAS?

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INDIVIDUAL NEEDS ASSESSMENT

CHECK ALL THAT APPLY TO YOU:

I don't know which majors would be a good fit for me.

I don't know which careers would be a good fit for me.

I will attend a minimum of two SSS events or workshops each semester (academic, financial literacy, retreats, and cultural).

High school did not prepare me for college.

I need to develop my writing skills.

I need to develop my math skills.

I achieved a GED.

I have been out of school for more than five years.

English as a Second Language Learner.

I need help to transfer.

Need for academic support (Low GPA, Failing Grades).

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TELL US ABOUT YOU

Please describe the main concern(s) you have about being in college.

How do you expect to use SSS resources to help you reach your goals and address challenges?

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COMMITMENT TO PARTICIPATE

If accepted into the Student Support Services Program, I agree to the following:

I will attend the SSS New Student Orientation.

I will meet with my SSS Advisor/TRIO Mentor regularly each semester.

I will submit a completed FAFSA application and at least one scholarship annually.

I will work with a counselor/academic advisor to obtain an academic plan.

I will attend all classes and complete coursework in a timely manner and participate in the tutoring program as needed throughout the academic year.

I will read emails, website announcements, newslettes and social media accounts.

I will communicate regularly with SSS staff regarding schedule changes, concerns that may affect school, when graudating, transferring, or leaving the SSS program.

I understand that I may lose my status as an SSS participant if I do not follow the terms of this agreement.

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AGREEMENT/RELEASE OF INFORMATION

I certify that the information I have provided on this application is to the best of my knowledge.

I hereby authorize the Student Support Services staff to access my academic records and to request attendance and performance information fromy my instructors on my behalf. I hereby authorize my instructors to release such information. I release the staff of Student Support Services and my instructors from all legal responsibility or liability that may arise from the actions I have authorized.

I give my consent for Triton College Student Support Services program to use my photo, video, and other images and provide information on my participation in the SSS Program on the SSS website, social meida account(s), brochures and newsletters. This agreement remains in effect duirng my years as Triton College.

Furthermore, I understand that by applying for the TRIO Student Support Services Program, I authorize the program staff to obtain records or data pertinent to my participation from other sources; such as but not limited to federal financial aid, monitoring educational progress, evaluate effectiveness of program activities, and fulfill program reporting requirements. To release and disclose information as required by law or the terms of the Student Support Services grant, to the grant fuding agency of the United States government. The Student Support Services program staff has my permission to communicate verbally and otherwise with staff, faculty, and/or off-campus professionals on my behalf.

Please provide your E-signature: *

Please select a signature verification type.