TRIO Student Support Services - Application
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First Name *
Last Name *
Student ID Number
Date of Birth (MM / DD / YYYY) *
Age *
Sex Identified at Birth *
Are you Hispanic or Latino? *
How do you describe your racial/ethnic background? *
Are you a US Citizen or Permanent Resident *
If you are Permanent Resident please enter your Permanent Resident number
Mobile Number *
Home Number
Email Address *
Do you already have a Bachelor's Degree?
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Prior to Simpson were you at a different College/University or High School? *
Enter the Month and Year you first started (or will start) at Simpson? *
Program *
What year are you currently in at school? *
Major *
Nursing Students Only: Please enter your semester
Have you been part of a TRIO program before? If so, which ones? *
Pleases indicate the highest level of education completed by the natural or adoptive parent(s) you lived with prior to age 18
Parent 1 *
Parent 2 *
Have you registered for disability accommodations with the Academic Success Center? *
Please select all that apply to you
College Preparedness (Select all that apply)
In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services program under the 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 Student Support Services program. The principle purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties.• By signing this application, I certify that all information provided above is true and accurate to the best of myknowledge.• I understand that all information on this application, as well as that released from the school, will be held in strict confidence by the TRIO Student Support Services program staff.• I authorize the release of academic records (e.g. copies of school transcripts, test scores) to Simpson's TRIO Student Support Services program in order to assess need/eligibility for program services, discern academic progress, evaluate the effectiveness of program activities, and fulfill program reporting requirements.• I consent to the disclosure of any personally identifiable information as defined by FERPA of my education records to Simpson's TRIO Student Support Services program staff for the purpose of confirmation of the student’s postsecondary enrollment status as reported on the National Student Clearinghouse Student Tracker. This authorization will remain in effect for six years following admission into Simpson's TRIO SSS program.• I authorize the release and exchange of student financial aid information from colleges and the federal government to the TRIO Student Support Services program.• I authorize the TRIO Student Support Services program to share and discuss information with school personnel in support of my student’s academic success.• I also give permission for the TRIO Student Support Services program to take photographs for identification purposes and during activities, and grant permission to use the student’s name, comments, and/or photos/videos for educational and/or promotional purposes.• I understand that this authorization will remain in effect while the student is enrolled in Simpson's TRIOStudent Support Services program or until written notice is provided to revoke the authorization.
Electronic Signature - Enter your full name below - This will complete your application to the TRIO Student Support Services. *
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