Ellsworth Community College

TRIO SSS Application

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If you have any questions, please contact the Program Director, Molly Hippen,

at 641-648-8511 or molly.hippen@iavalley.edu.

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STEP 1- Personal Data

First Name *

Middle Name

Last Name *

Social Security Number *

Date of Birth *

School ID *

Gender *

Are you a U.S. Citizen? *

Address *

Address cont.

City *

State (two letter code) *

Zip *

Cell Phone Number *

May we please text you? *

Personal Email Address *

Semester Start

STEP 2- Ethic Background

Ethnicity:

Are you Hispanic or Latino? *

Race (please select 'yes' for all that apply):

American Indian or Alaskan Native *

Asian *

Black or African American *

Hawaiian or other Native to Pacific Island *

White *

STEP 3- Parental Information

Have either of your parents received/earned a 4-year college degree? *

STEP 4- Financial Information

According to your financial aid, are you a Dependent or an Independent? *

Taxable income on IRS Tax Form 1040 can be found on line 15.

Option 1: I certify that my family's taxable income for 2023 was $_______ and my family size was _____ .

Option 2: My family field a foreign tax return. I certify that my family's taxable income for 2023 was $_______ and my family size was _____ .

Option 3: I certify that my family had $0 taxable income for the 2023 tax year.

Selection one of the three options *

Taxable Income Amount (Option 1 or 2 only):

Family Size (Option 1 or 2 only):

STEP 5- Disabilities Status

Do you have a diagnosed disability? (Physical, learning, and/or psychological)? *

If you indicated that you have a diagnosed disability above, have you registered with the accommodations office?

STEP 6- Services you may need

Please check all services that Ellsworth Community College TRIO SSS program offers that you think you would use:

Tutoring

Financial Aid Completion Assistance

Academic Advising

Financial Literacy Workshop

Choosing a Major

Academic Skill Building Workshop

Career Guidance

Goal Setting

Transfer Advising

Please check any of the following areas that you feel you need to improve on:

Math Skills

Study Skills

Academic Advising

Time Management

Study Habits

Writing Skills

Note Taking

Test Taking

Reading Skills

Computer Skills

STEP 7- Educational Information

Have you graduated from high school?

If so, what year did you graduate?

Did you earn your diploma, GED, or neither?

ECC Plan of Study (Major):

STEP 8- Other Programs

Please select any sports you participate in through ECC (select all that apply)

Baseball

Softball

Women's Basketball

Men's Basketball

Cheer/Dance

Football

Women's Wrestling

Men's Wrestling

Softball

Volleyball

Trap Shooting

STEP 9 - Acknowledgement

I understand that if I enroll in the Student Support Service I must participate in activities designed to achieve my academic goals and promote my holistic development.

1. Release, I hereby give permission for the release of the following information to the Student Support Service Staff: High School transcripts, college grade reports, SAT/ACT or ACCUPLACER scores, financial aid award/FAFSA/IRS information, billing information and, if applicable, documentation regarding status as an individual with a disability or any other information regarding my status as a Ellsworth Community College student. I give Student Support Services permission to use photographs of me on websites, brochures, or program related publications.

2. Privacy Act, I understand the information contained herein will be kept in confidence and will not be revealed to anyone except Student Support Services personnel, Ellsworth Community College official, or representatives of the United States Department of Education and in accordance with the Family Education Rights and Privacy Act (FERPA).

3. I certify that all that information provided on this application is true to the best of my knowledge. I also understand that any false information I have provided may result in the denial of my application and/or my immediate dismissal from the program.

Date of Signature:

Electronic Signature: