TRIO Application - Tyler Junior College

TRIO Application

Note to the students: All information stated on this form will be held in confidence by the project coordinator and staff. Answer all questions. If a question does not apply to you, complete the blank with a N/A.

Social Security Number:

Name:

Address: City Zip

Home Phone Work Phone

E-Mail Address

Date of Birth Birth Place Male Female

Please give the name and telephone number of a person with whom we can leave a message, if you are not available at home.

Name Phone Number:

Tyler Junior College Support Services TRIO is federally funded program under the Department of Education. Students participating in the program's activities must meet certain requirements set forth by the Department of Education. To determine your eligibility, please fill out the following information as completely as you can.

High School Diploma or GED Date received

If High School diploma, name of school

Did you ever take, currently enrolled or need to take a developmental class? Yes No

Have either of your parents (natural/adoptive) received a bachelor's degree? Yes No

If your parents received a degree in a foreign country, are they able to use it in USA? Yes No

Father's occupation Mother's occupation

Are you a U.S. citizen, a permanent US resident, or a trust resident? Yes No

If no, what kind of visa do you have?

Is English your native language? Yes No

Please check any and all program from which you or family receive assistance:

AFDC
JTPA
Social Security
Food Stamps

Veteran's Benefits
TRC
SSI
TCB

Unemployment insurance Other (please specify)

Yearly income before taxes $
Household income if living with family; personal income if self-supporting and living away from family)

Number of persons dependent on this income

Do you have an application for financial aid and a Parent's Confidential Statement on file in the Tyler Junior College Financial Aid Office? Yes No

If no, please bring a copy of your IRS 1040 or a copy of your parents' IRS 1040 if they claimed you for the previous year.

Please list amount awarded under the following programs:

Federal Pell Grant $ Presidential Scholarship $

Federal Supplemental Educational Opportunity Grant (FSEOG) $

Dean's Scholarship $

Texas Public Educational Grant (TPEG) $

Faulconer Academic Incentive Award for Ethnic Minorities $

Texas Public Educational-State Student Incentive Grant (TPE-SSIG) $

Valedictorian Scholarships $

Campus Work Study (CWS) $

College/Endowed Scholarship $

Student Assistants' Employment Program $

Athletic Performance Grants $

Off Campus Employment $ Performance Grants $

Loans (Stafford, etc.) $

Veterans' Services (G.I. Bill, Hazelwood, etc.) $

Other (Please specify) $

Do you have a physical/learning disability? Yes No
If yes, please specify documented disability:

Do you plan to transfer to a 4-year college or university? Yes No

What is your major?

Please indicate all the areas in which you have an interest in participating:

Cultural Enrichment Activities
Individual Academic Counseling
Tutoring

Study Skills Seminars
Financial Aid Information and Guidance
Financial Planning Workshops

Scholastic Probation Prevention

Academic Advising and Placement

Individualized Instruction TASP Preparation Seminars

University Transfer Information Information and Referral Assistance

Other (please specify)
I understand that if I enroll in any phase of the Support Services TRIO Program, I will participate in activities, (seminars, group sessions, tutoring, cultural programs, etc.) designed to achieve my academic goal and promote cultural growth. I also certify that the above information is true and correct to the best of my knowledge. In addition, I hereby give permission to all governmental agencies to release copies of my financial, academic and medical records.

Date:

Comments:

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Support Services:
   Adult Student Services
   Disabilities Services
   Interpreter Training Program
+ TRiO Program
   Tutoring Services

The TRiO Program is a specialized program offered by the Office of Support Servies.

TRiO Information:
Application
Plan for Success
Newsletter
Calendar
Contact

Contact TRiO:
Hawkins, Reneé
Project Coordinator
Phone: (903) 510-2495
email: rhaw@tjc.edu