TRIO Talent Search 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

If you are a permanent resident, please provide your alien registration number

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

Yes
No

Are you living with that parent?

Yes
No

Do you have a documented disability?

Yes (including if you had an IEP in high school)
No

Have you applied for Financial Aid?

Yes
No

Are you receiving the Pell Grant?

Yes
No

Educational Information

What grade are you currently in?

What school are you currently attending?

Have you completed ACCUPLACER Testing?

Yes
No

Completed ACT testing?

Yes
No

Do you have a high school diploma?

Yes
or a GED?
No

Date received

Name of high school

Expected high school graduation date

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
Future plans to attend high school
To take courses to transfer
To complete a certificate
To obtain an Associates Degree and then transfer to a 4 year univiersity

Other

In your own words, please explain briefly why you want to participate in the TRIO Talent Search Program

Services Available

Other assistance you would like to receive

Authorization

1040 Taxable Income (Line 15)

Household size

Student Signature

Date

Parent/Guardian Signature

Date

TRIO Talent Search Program Dodge City Community College 620-227-9296 This is a funded publication by the U.S. Department of Education (Grant #P044A210400) Your privacy is important to us. Please send application and supporting documentation to our secure file link: https://liquidfiles.dc3.edu/filedrop/groberts