TRiO Application Cochise College TRiO Student Support Services TRiO SSS is a federally funded program Step 1 of 6 16% Student Information(If Applicable) Referred By: First Last Name* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* MM slash DD slash YYYY Gender* Male Female Student ID (C#)*College Email* @students.cochise.eduHome Phone*Cell PhoneEthnicity* American Indian / Alaskan Native Native Hawaiian / Pacific Islander Hispanic / Latino African American Asian White Other More than one group Eligibility InformationCitizenship Status* U.S. Citizen Permanent Resident *Dream Act students are not eligible for program services due to federal requirements of the TRiO SSS grant.Permanent Resident A#:*Academic / Skills Needs*Please check all the provided services you may need. Academic Advising Career Exploration English Language Development (ELD or ESL) Financial Aid Assistance Scholarships Search Study Skills Transfer Assistance Tutoring First GenerationHas your natural or adoptive mother earned a bachelor degree from a four-year institution?* Yes No Has your natural or adoptive father earned a bachelor degree from a four-year institution?* Yes No Which parent did you regularly reside with and receive support from during your childhood (i.e. until you were 18 years old?* Both Father Mother Neither DisabilityDo you have a disability?* Yes No Is your disability documented with Cochise College Disability Services?* Yes No Are you receiving accommodations? Yes No Type of disability?* Learning Physical Medical Other Financial InformationHave you applied for the FAFSA (Financial Aid)?* Yes No Do you receive and/or qualify for Financial aid?* Yes No Unsure *Please see the attached Income Statement for complete financial verification.AcademicsDo you have a High School diploma?* Yes No Date you received High School diploma:*(MM/YYYY, ex: 05/2013)Have you completed a GED?* Yes No Date completed GED:*(MM/YYYY, ex: 05/2013)Name of High School:*Did you transfer from another college?* Yes No Have you ever received a bachelor's degree?* Yes No What semester and year was your first at Cochise College AFTER H.S. Graduation?*(ex. Fall 2019)What is your declared major at Cochise College*Are you a previous TRiO SSS Student? Yes No Do you plan to transfer and pursue a bachelor degree?* Yes No Undecided TRiO WhatsApp Permission By filling out this section, you understand that you will be placed into the TRiO WhatsApp group where your phone number will be visible to other students. You may opt out, however you will not receive text messages. Everything that is sent by text will also be sent to your student email. You DO NOT have permission to call others in this group, unless you have that person's permission. Failure to comply with this will lead to your removal from this WhatsApp group.Your Student Email:* @students.cochise.eduName* First Last Student ID# (C#)*C00XXXXXXCan we add your phone number to the TRiO WhatsApp Group?* Yes (By checking this box you are allowing your number to be visible to everyone in the group) No (You will not have your number shared and will not receive text messages) Please Add Cell Phone Number Below (Out of State or International Numbers ok)* Disclaimer and CertificationI authorize TRiO SSS program staff to obtain academic records or data pertinent to my participation from other departments, and programs including grades and any financial aid information prior to my participation and throughout my involvement in TRiO SSS. TRiO is a grant funded program and as such must submit an annual progress report to the Department of Education. I understand that TRiO will continue to report on my academic progress throughout the required reporting period. I understand that if I enroll in TRiO SSS, I am EXPECTED to attend the TRiO Orientation, TRiO workshops and appointments with a TRiO Advisor as directed to complete a Student Success Plan (SSP). I shall attempt to participate in as many activities (group sessions, tutoring, college tours, etc) as my schedule will allow, which are designed to achieve my academic goals and to promote personal growth. I also commit to maintain at least a 2.5 GPA to the best of my ability. I also allow TRiO SSS to publish pictures of myself on social media and/or print of trips, tours and community involvement. If I do not participate or put in a good faith effort to follow through with my Participation Agreement, I will be placed on inactive status from TRiO SSS. I certify that the above information is true and correct to the best of my knowledge.* I Agree. Electronic Signature*Please print first and last name Income StatementEach applicant for the TRiO SSS program shall provide ONE of the following: ✓ Signed statement of income from a dependent student's parent or legal guardian ✓ Signed statement of income from an independent student ✓ Verification of income from another governmental source ✓ Signed financial aid application✓ Signed U.S. or Puerto Rico Income tax return This form can serve as a SIGNED STATEMENT OF INCOME. Please use a copy of the 2023 1040 federal tax form, if applicable, to complete the table below. Although financial need is not a requirement to join TRiO SSS, all financial information must be received before eligibility can be determined.Complete this section to serve as a Statement of IncomeName of student applying for TRiO SSS* First Last Student ID (C#):*Indicate whether the student is Independent or Dependent. A DEPENDENT student is under the age of 24 (even if you don’t live with your parent(s) or adoptive parent(s). Dependent students should ask their parent(s) or legal guardian(s) to complete the questions related to their financial information. Parent or legal guardian should sign the form. An INDEPENDENT student meets one of the following: • 24 yrs old as of January 1, 2023 • Has legal dependents (children) (only if you provide more than 50% of their support) • Married • Veteran (US Armed Forces) • Was/is in foster Care or legal guardianshipI am a(n):* Dependent student Independent student Name of parent/guardian completing the Income Statement for a dependent student.*For the 2023 tax filing, list the size of the family/household. If you did not file taxes, how many people are in your family/household?*For the 2023 tax filing, write the figure listed for TAXABLE INCOME as reported on your tax return. If you did not file taxes, write the estimated taxable income. If it was zero, write, “0”*I certify that the information I have furnished regarding the size of my family and taxable income is true to the best of my knowledge.* I Agree. Independent Electronic Signature*Please print your first and last nameStudent Electronic Signature*Please print first and last name.Parent Electronic Signature*Please print first and last name. THIS PAGE IS FOR YOU After reading, please hit the submit button at the bottom. Thank you for your interest in becoming a participant in the Cochise College TRiO/Student Support Services Program! Please read and complete this application thoroughly. ABOUT TRiO/STUDENT SUPPORT SERVICES “TRiO” refers to a series of programs, funded under Title IV of the Higher Education Act of 1965, created to assist disadvantaged Americans in overcoming class, social and cultural barriers to higher education. The term TRiO was coined to represent the initial three programs, Upward Bound, Educational Talent Search, and Student Support Services. Student Support Services Program was created to… • Improve the graduation and retention rates of first generation (neither parent/ guardian has a bachelor’s degree), low-income, and disabled college students; • Assist students in achieving academic success given their academic potential and the efforts they invest in their academic endeavors; • Facilitate their entrance into undergraduate and professional school programs; and • Foster an institutional climate supportive of the academic, cultural, and personal success of the participants. CONFIDENTIALITY OF INFORMATION As a federally funded program, TRiO/Student Support Services reports to the U. S. Department of Education. In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), the Department of Education is authorized to collect information to implement the TRiO/Student Support Services Program under 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 program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. TRiO/SSS SELECTION PROCESS: The Cochise College TRiO Student Support Services Program is funded to serve 165 eligible students each year. Because there are more eligible students at Cochise College than the TRiO/SSS program can possibly serve, priority is given to those applicants who demonstrate the most need, the greatest academic potential, and the motivation to make full use of TRiO/SSS services to become a successful college graduate. Thus, students are selected as follows: 1. Students who are both low-income eligible and first generation college students 2. Students with a disability who are low-income 3. Alumni of other TRiO programs: Upward Bound, Talent Search, or another Student Support Services program (I.e. transfer students who were participants at another college or university);4. Students with educational histories that reflect a need for academic support in order to be successful in college (low college math placement, uneven high school record, problems with reading, writing, or study skills, uncertain career and educational goals) and 5. MOST IMPORTANTLY, students MOTIVATED to make full use of TRiO/SSS services to become a successful college graduate.CAPTCHA Δ
