TRiO Student Support Services Today's Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Name * Gender Female Male Trans Female Trans Male Gender Queer or Gender non conforming Self Identify Self Identify Gender Race and Ethnicity (check all that apply) Native American/Alaskan Native Middle Eastern Multi-Racial/Multi-Ethnic Asian Black/African American Native Hawaiian/Pacific Islander Latina/o White Self Identify Self Identify Race Birthday Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Student ID A# * Citizenship U.S. Citizen Permanent Resident Resident Alien Card# Attach photo copy of card Home Phone Cell Phone Evergreen E-Mail * Evergreen Registration Status Full-time Part-time Please check all that apply to you as a student Direct from High School Transfer Student Conditional Admit Out of school longer than 5 years Single Parent Working more than 20 hours/week Commute more than 40 miles/day round trip Check any of the circumstances that you feel apply to you: Poor study skills Childcare issues Taking the wrong classes Afraid to speak up in class or seminar Too shy Test anxiety Taking things too seriously Lack of family/friend support Family/personal medical problems Unsure of goals Financial issues Constant worrying Time management Separation or divorce Feeling depressed or sad Transportation Trouble sleeping Problems at home Other Other Circumstances Check any of the following services that may interest and/or benefit you: Academic assistance Career planning Scholarship planning Tutoring Overcoming test anxiety Seminar tips Personal Budgeting Financial Aid/FAFSA Tips on effective writing Stress management Developing study skills Are you eligible for the Program? (please check all that apply) You will be the FIRST in your family to graduate with a Bachelor’s Degree (Your custodial parent(s)/guardian(s) do not have a Bachelor’s Degree or Higher) You have any documented physical or learning disabilities You are receiving funds or services from L&I, DVR, and/or SSI You applied for financial aid for the current year You received financial aid To qualify as low income, the U.S. Department of Education requires verification of income. In order to process an application under this category, we need at least one form of documentation. If you have not filed a FAFSA for the current academic year, we will require an alternate form of income verification. Is your disability documentation on file with Access Services for Students with Disabilities? Yes No If you qualify for services based solely on your disability, you must have documentation with Access Services. Funds or services are from: L&I DVR SSI Types of Financial Aid: Pell Grant Other Grants Loans Work Study Scholarships
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