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Thank you for your interest in our Student Support Services Program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application.  If you have any questions, please email

Biographical Information:
First Name: *
Middle Name:
Last Name: *
Date of Birth: *
School ID:
Address: *
Address Line 2:
City: *
State: *
Zip Code: *
Home Phone:
Cell Phone Number:
Email Address:
Preferred Name:
Are you a United States Citizen or Permanent Resident? *
Non-citizen's U.S. Visa Number (if applicable):
Race Classification (for statistical purposes only):
Are you Hispanic or Latinx?
Do you have a documented disability? *
Have you submitted documentation of your disability to the Accessibility & Resource Services office at Shawnee Community College?

Educational Information:
High School Graduation Year (if applicable):
GED Completion Year (if applicable):
Parent or Guardian #1 Highest Level of Education Level: *
Parent or Guardian #2 Highest Level of Education Level: *
Which do you plan to complete at Shawnee Community College?
What is your intended major?
Have you attended another college or university?
If so, what other school(s)?
Have you already completed a 2-year or 4-year degree?
If so, which degree and from which school?
Do you plan to transfer to a four-year institution to complete a Bachelor's Degree
If so, where do you plan to transfer?
What is your intended major at that institution?

Intake Assessment:
Give us a brief description about yourself:
Who resides in your household?
Why did you decide to attend Shawnee Community College?
Are you aware of any problems or barriers or responsibilities that might interfere with you obtaining your goals?
Do you work anywhere?
If so, where?
Approximately how many hours per week do you work?
Are you a member of a club/organization or are you an athlete at Shawnee Community College?
If so, which club(s), group(s) or team(s)?

Academic Needs:  My skills in each of the areas below are:  
Study Skills
Courses (if any) that I might need tutoring in:
Have you previously participated in any of the following TRIO programs?

Financial Aid & Financial Literacy Knowledge:
I have completed my FAFSA?
I would like assistance completing the FAFSA and/or financial aid advising
I could use assistance with money management
I would like help finding and applying for scholarships

Please write 3-5 sentences about your educational goals.
Write 3-5 sentences about why you are interested in participating in TRIO: Student Support Services.
How did you hear about Student Support Services (SSS)? Please list anyone that referred you.

Sign and Submit:

Certification and Release of Information: 

The information on this form is confidential and will help determine eligibility for Student Support Services (SSS).  I declare that the information given here is true and correct to the best of my knowledge.  I authorize Student Support Services access to my student records, including academic records, financial aid awards, and any other information pertaining to my enrollment in SSS.  Additionally, if I transfer to another institution, I authorize SSS to contact said institution and/or the National Student Clearinghouse for follow-up information.   Further, I authorize Shawnee Community College TRIO: SSS to release information as required by law or the terms of the TRIO: Student Support Services grant to the grant-funding agency of the federal government (Federal Department of Education).  

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Signature: (Type in your full name)
I agree to the terms included.

Office Use Only:

Advisor Signature:  _______________________________________________  Date:  __________

Director Signature:  _______________________________________________ Date: ___________

FG ______  LI _____ D _____ FG/LI _____ D/LI _____

Acceptance Date:  _____________   Semester _______

1st year never attended ____ 1st year attended before (below 30 hours) ____ 2nd year ____

Current Cumulative GPA _________  Dual Credit/Escrow?  Y  N