Ellsworth Community College

TRIO SSS Application

______________________________________________________________________________________________________

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

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

__________________________________________________________________________________________________________________________________________________________________

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? (Only mark independent if Parent income information was not needed for FAFSA) *

Taxable income on IRS Tax Form 1040 can be found on line 15. Previous tax year defined as (example: year 2025-2026 academic year we are needing 2024 tax information). In order to verify income we must also receive a copy of parent/guardian 1040 tax return for previous year. Please email tax documents to the Program Director.

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

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

Option 3: I certify that my family had $0 taxable income for the previous 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? If no, please send documentation to ECC Accommodations office to verify)

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.

Release of Information:

I understand and agree that TRIO-SSS staff has access to information relevant to my academic status including enrollment data, test scores, transcripts, grades, financial aid verification, verification of disability status, and progress reports. Prior to my admission into the TRIO-SSS program, this information will be used to confirm my eligibility, and if accepted as a TRIO-SSS participant, this information will be used to help me meet my goals at Ellsworth Community College.

I understand that TRIO-SSS staff may exchange information pertinent to my educational goals, plans and progress with Ellsworth Community College faculty and staff from various departments including Registrar, Financial Aid, Academic Advising, Disability Support Services, Institutional Research/Planning, Testing and Instructional Departments.

I understand the TRIO-SSS staff may exchange information with other colleges and universities to assist in transfer planning and verify admission.

I understand that, in accordance with Family Educational Rights and Privacy Act (FERPA), my education records are protected. By signing this form, I authorize TRIO-SSS and Ellsworth Community College to use photographs and/or video recordings of me taken during TRIO-SSS activities for educational, promotional, and program-related purposes.

I understand that these materials may be used in official college or program publications, including websites, social media, brochures, newsletters, reports, and other marketing or informational materials. I further understand that this authorization is voluntary, that I may revoke it in writing at any time, and that no compensation will be provided for such use.

By signing below, I acknowledge that my electronic signature is an original signature. I understand and agree to the TRIO-SSS Release of Information policies and maintain that all information I have provided on this application is accurate to the best of my knowledge.

Date of Signature:

Electronic Signature (Please select simple):

Please select a signature verification type.

Iowa Valley Community College District does not discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, actual or potential family, parental or marital status, or other protected classes. If you have questions or complaints related to compliance with this policy, please contact the Vice President of Administration, serving as the District Equity Officer, 3702 S. Center Street, Marshalltown, IA 50158, 641-844-5530, Equity@iavalley.edu, or the Director of the Office for Civil Rights, U.S. Department of Education, Cesar E. Chavez Memorial Building, 1244 Speer Boulevard, Suite 310, Denver, CO 80204-3582, Telephone: (303) 844-5695 FAX: (303) 844-4303, TDD 800-877-8339 Email: OCR.Denver@ed.gov.