Skagit Valley College TRIO Student Support Service Program Application

The following information is requested to determine your eligibility for program services. Your information will be used for federal reporting as required by the U.S. Department of Education and used to determine the effectiveness and accountability of our programs.TRIO programs are funded by U.S. Department of Education.  Please answer each question.  All information provided will be kept confidential. 

PRIOR TO FILLING OUT THIS APPLICATION, please consult our website for eligibility requirements. www.skagit.edu/trio-support-services. 

Items you will need to complete the application: 
1) Student ID number 
2) Last year's Taxable Income from federal tax forms (1040, 1040EZ, 1040A)
 
Priority will be given to students who are both First Generation and Low Income.
Name and Contact Information

MM/DD/YYYY





MM/DD/YYYY



TRIO SSS participants will be automatically added to a TRIO distribution list






Message and data rates may apply.



Demographic Information


Financial Eligibility




Annual Taxable Income from last year’s tax return may be found on:Form 1040 Line 43; Form 1040A Line 27; Form 1040EZ Line 6

Annual Taxable Income from last year’s tax return may be found on:Form 1040 Line 43; Form 1040A Line 27; Form 1040EZ Line 6
Educational History & Goals














(i.e. locations, lighting, desk, time of day, etc.)





Needs Assessment

Affidavit of Truth Statement & Release of Information
I authorize the TRIO Student Support Services program staff to:

• Gather information concerning all my academic progress (standardized test scores, grade point average, earned credit, transcripts, tutoring, etc.) and financial aid reports including Federal taxes, FAFSA and verification of income prior to my participation in the program; 

• Verify my claims of a documented disability with SVC Disability Services; 

• Gather information for follow up whenever appropriate, including but not limited to, transfer and progress to other academic institutions; Report my eligibility, GPA, and financial aid status to the US Department of Education in accordance with the grant funding; 
• Use my name, photo or information about me in media sources.       

I certify to the best of my knowledge, statements I have made on this initial information application form are complete and true. Failure to disclose and submit complete and accurate information, may result in the denial of acceptance to Skagit Valley College TRIO Student Support Services Program. 

I understand that being eligible does not guarantee admissions into the TRIO Program.


Participation Agreement
As a TRIO Student Support Services participant, I agree to meet the policies as set forth below:
 
1. Appointments: I will meet with my SSS Advisor a minimum of once per quarter.  Appointments will focus on my educational plan, academic progress, learning strategies, and problem solving support. NO SHOWS:  If I miss two or more consecutive appointments without notification to the SSS office or my SSS Advisor, I may lose program benefits.  Program benefits may include: one-on-one tutoring, cultural enrichment events, and more. In addition, I will provide the TRIO SSS program my best method of contact.
 
2.  Withdraw: If you withdraw or stop attending classes between fall quarter and the following fall quarter, you may be requested to reapply to continue to utilize TRIO services. 
 
3. Commitment to Attend a Cultural Enrichment Event: If I RSVP to attend an SSS event and then fail to follow through or provide proper notification (Proper notification time frame varies based on event) to the SSS office that I am unable to attend, I will be unable to participate in any more trips for the rest of the year.
 
4. Tutoring: I will first utilize the free drop-in tutoring available on-campus through the Tutoring Center.  If none are available, I will submit a tutor request to TRIO SSS. I will meet with my tutor on a regular basis according to the hours authorized. I will notify the tutor at least 24 hours in advance if I cannot attend the tutoring session.  I understand I may lose tutoring benefits should I have more than two NO SHOWS.  I also will notify the SSS office within 24 hours should my tutor not show up for a scheduled session.
 
5. Grades & Academic Deficiency: If I have any “C-“or below grades at midterms, I will meet with my SSS Advisor to discuss academic strategies. If I was academically deficient (Quarter or CUM GPA below 2.0) during the previous quarter, I will complete the Academic Improvement Plan to ensure I am not deficient in subsequent quarters.
 
6. Degree Requirements: I will become more aware of my degree requirements for my degree/certificate and discuss challenges and needs in obtaining and maintaining good academic standing with my SSS Advisor.
 
7. Financial Aid and Scholarships: a. If eligible, I will apply for financial aid by completing the FAFSA (at www.svc.edu) b. Regardless of GPA or class standing, I will submit the SVC Scholarship application for the next academic year by the deadline provided to me by SVC. c. If I need assistance in completing the FAFSA or SVC scholarship applications, I will meet with my SSS Advisor.
 
8. Confidentiality: All issues discussed between you and your SSS Advisor is confidential.  However, information relevant to helping solve problems for you may be shared with other SVC staff, unless you instruct us otherwise.  If there is an active situation of child abuse or elderly abuse, imminent danger to self or others, or if subpoenaed by the court, the SSS Advisor may be legally obligated to release relevant confidential information.
 
9. Release of Information: a. At times, SSS will take photos or video of our participants using program services (tutoring, attending workshops or cultural enrichment events, etc.). May we use your likeness in publications, online, etc. to promote our campus and the SSS program?  b. May we use your name for recognition in e-mails, newsletters, etc.?  For example if you made the President’s Honor Roll, received an award or recognition, or received an internship, etc.

I understand that entering my first and last name below, and submitting this form, constitutes a legal signature.  All authorizations for release of information are effective only for the academic year in which they were submitted.