Information received on this application will be held highly confidential.
Theapplication and any part of its contents will not be released to anyone other than program staff without a written statement from you. Please sign and date below if you agree to the following:
* All of the information on this application is true and accurate to the best of my knowledge. The college reserves the right to admit or deny any student enrollment in the TRiO/SSS program.
Completion of this application does NOT guarantee acceptance into the program.
I understand that I will not be eligible to participate in the TRiO program until successful completion of all 0306 developmental courses.
*If accepted into the program, I agree to allow my name and/or picture to be printed in any TRiO newsletter, publication, or display in recognition of academic success, leadershiip, or graduation. I also agree to meet with my TRiO advisor at least once each semester and notify the program if my contact information changes or I change my academic plans.
*I give permission to discuss issues related to myacademic progress
with any other college faculty and./or staff for thepurpose of coordinating academic and personal support services
as long as I am an active participant of the program.
I intend to complete my associate degree through KC within four years of acceptance into the TRiO Program and transfer to a four-year university.
For Staff Only:
Director's Signature: ____________________ Date: __ __/__ __/__ __ __ __
TSI Level: M _______ R_______ W _______Academic Need
Cohort Year: ________
Accpt'd w/following eligibility:
__1st Gen/LI __1st Gen Only __ LI Only __ D/LI __ D Only
Low Income Status
__ Y __N __ Req
___Y ___N ___Req