TRIO Student Support Services Application

Student Support
TRIO Student Support Services Application

Student Support Services Project

TRIO Student Support Services Application

TRIO SSSP Application

B��Ԫ

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TRIO Student Support Services Project Application

TRIO Student Support Services Project (SSSP) at B��Ԫ is a federally funded grant program of the United States Department of Education that provides opportunities for academic development. Services are intended to assist students with basic university requirements and motivate students towards the successful completion of their post-secondary education.

We invite you to complete and submit this application for consideration for TRIO SSSP. If you have any questions regarding this application or SSSP, please call (914) 674-7747 or (718) 678-8851 and ask to speak with an SSSP counselor.��

Thank you for your interest in the Student Support Services Project. Good luck at B��Ԫ!

Funded by the United States Department of Education P042A200411

Status

Name*

First Name*

Last Name*

CWID*

University Wide Identification Number

Date of Birth*

MM/DD/YYYY

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone *

Preferred Number

Business Phone*

Email*

Preferred Email

Gender

Male Female

Marital Status*

Single Married Separated Divorced Widowed

Race*

Black/ African American Hispanic/ Latino Caucasian Asian American Indian/ Alaska Native Native Hawaiian/ Pacific Islander More than one race

Citizenship Status*

U.S. Permanent Resident

Alien Registration Number

Country of Birth, if not the United States

Native Language

*The next two questions are to determine if you qualify for the program based on a disability

Do you have a physical disability?*

Yes No

Please list nature of disability

Have you been diagnosed with a learning disability?*

Yes No

If so when?

In case of emergency contact (Name):*

Relationship*

Phone*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

EDUCATIONAL BACKGROUND

Do you have a High School Diploma?*

Yes No

List graduating High School:

Do you have a GED?*

Yes No

Are you a transfer student?*

Yes No

List college(s), business schools, nursing schools, or vocational schools beyond high school you attended before coming to B��Ԫ:

Please include the city/ state

Were you in an opportunity program? (ex: EOP, SEEK)*

Yes No

If yes, please select program

Did either of your parents graduate from a U.S. college or university with a Bachelor's degree?*

Yes No

If yes, which college/ university did they graduate from?

Please list the college, city, state

FINANCIAL INFORMATION

Are you dependent or independent of your parents, or guardians, income?*

Dependent Independent

If you are dependent, do you have children that are dependent on your parent's, or guardian's income?

Yes No

If you are independent, do you have children that are dependent on you and/or your spouse's income?

Yes No

HOUSEHOLD INFORMATION (please list Name/ Age/ Relationship of the members of your household)*

Please include yourself

CAREER

Intended Major*

Career Goal(s)*

How did you hear about the program?*

Student Signature*

[clear]

Use your mouse or finger to draw your signature above: I certify that all information provided in this application is accurate to the best of my knowledge

Date of Signature*

SSSP Counselor Signature & Date

STUDENT CONTRACT

Name*

First Name*

Last Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Preferred Phone Number*

CWID*

Preferred Email*

I understand that the Student Support Services Project is a federally funded program, and my selection to participate in the program is based on my meeting the federal eligibility criteria. ��I agree to actively participate in the Student Support Services Program, which is designed to provide academic and other support services to help me succeed at B��Ԫ. ��The program has been explained to me and I fully understand the services it provides. ��If admitted, I am willing to make a commitment to take responsibilities and adhere to the following:

I agree to meet with my counselor at least three times each semester.

I agree to promptly submit��all documentation pertaining to program eligibility and financial aid. ��Example: proof of income, FAFSA, SAR, TAP awards, etc.

I understand that my academic progress will be monitored by Student Support Services Program’s staff during my tenure at the university.

I agree to complete each semester that I register for and to consult with my SSSP advisor prior to dropping or withdrawing from a class.

I agree to actively participate in the activities specified by the Student Support Services Project as needed and recommended by the staff.

I agree to attend all COP/TRIO-SSSP general meetings.

If I am referred for tutoring I agree that I will attend and understand that my participation in tutoring will be monitored.

I have received the General Guidelines for the University Opportunity Program (SSSP), and I understand failure to comply with these conditions may result in program dismissal.

STRUCTURED INTERVIEW

1. Why did you decide to go to university?

Social reasons (make friends, develop socially) Conformity (decision made by someone else; expected of me) Vocational reason (degree of education; needed to work) Academic reason (enjoy studying; value education) Material value (economic, security, advancement) Other

2. Was B��Ԫ your first choice?

Yes No

How do you feel about coming to B��Ԫ as opposed to other colleges or universities?

3. When did you decide to attend university?

Was always expected In high school or junior high After high school While in the military or shortly thereafter Within the last three months Other

4. Whose decision was it that you go to university?

My own My parents/ family Other

5. What do your family and friends think about you coming to college?

Unsure Supportive Non-supportive

6. What is the highest level of education you would like to attain?

No specific plans Associate degree Bachelor degree Graduate degree

7. Do you plan to complete your degree at B��Ԫ?

Yes No

8. What are you interested in studying?

9. How long do you think it would take you to graduate?

10. What are your plans after graduation?

11. What do you think you'll enjoy most about coming to the university?

12. Do you have any fears or anxieties about coming to the university?

13. How would you describe your High School experience?

Positive experience So-So experience Negative experience

In order to process your application please email a copy of your:

-Birth Certificate/Permanent Resident Card/Naturalization Papers/Passport

AND

-If you are a dependent, a copy of your parents’ 2023 Federal Tax Return.

-If you are independent, a copy of your own 2023 Federal Tax Return.

To dcollins@mercy.edu��

If you have any questions, please feel free to contact:

David Collins, Director

dcollins@mercy.edu

914-674-7239

Walter Zea, Counselor (Dobbs Ferry)

pzea@mercy.edu

914-674-7738

Smita Jitlall, Counselor (Bronx)

sjitlall@mercy.edu��

718-678-8851

Kathleen Rapley, Administrative Assistant

krapley@mercy.edu��

914-674-7747

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