TRIO Student Support Services Application - Dodge City Community College

Name *

First

Middle

Last

Social Security Number

Date of Birth

Preferred Name *

Gender

Other
Male
Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Best Time to Call

Email *

Someone who can always receive your mail or be contacted in an emergency *

First

Middle

Last

If you chose Other, please specify here

Eligibility

What Country were you born in?

Are you a U.S. Citizen or permanent resident?

Yes
No

Has either parent completed a four-year Bachelor's degree?

Yes
No

Are you living with parents/are you dependent?

Yes
No

Are you an independent student?

Yes
No

Do you have a documented disability? (Mark Yes if you had an IEP in high school)

Yes
No

Have you applied for Financial Aid?

Yes
No

Are you receiving the Pell Grant?

Yes
No

Educational Information

Intended Major

First Semester at DCCC

Have you completed ACCUPLACER Testing?

Yes
No

Have you registered for classes?

Yes
No

Do you have a high school diploma?

Yes
or a GED?
No

Date received

Name of high school

Location of GED test

What is your educational objective? (check all that apply)

No definite purpose in mind
To obtain a vocational A.A.S. degree
To take a job-related course
To take courses to transfer
To complete a certificate
To obtain an Associates Degree and then transfer to a 4 year univiersity

Have you attended college elsewhere?

Yes
No

If yes, where? Include name of institution city, state and year.

In your own words, please explain briefly why you want to participate in the TRIO Student Support Services program.

Services Available

Other assistance you would like to receive

Authorization

I authorize the TRIO Talent Search Program to obtain, copy, review, and discuss records with DCCC faculty and staff including:

High School Transcript
Transcripts from other colleges
Financial Aid records
Standardized test scores
Course registration for each semester
Academic progress including final grades and transcripts
Disability Documentation
Most recent signed copy of IRS tax form 1040

I understand that the college reserves the right to admit or deny any student enrollment in the TRIO SSS program. Completion of the application does not gurantee acceptance into the program. I certify that all of the above stated information is true and correct to the best of my knowledge and abilities.

Student Signature

Date

TRIO Student Support Services Dodge City Community College 620-227-9296 This is a funded publication by the U.S. Department of Education (Grant #P042A200085) Your privacy is important to us. Please send application and supporting documentation to our secure file link: https://liquidfiles.dc3.edu/filedrop/groberts