Personal Information:
Name: (First) ____________________________(Last)_____________________________(MI)________
Date of Birth: ______/______/______ Gender: M F
Student ID#:_________________________ Social Security Number: ____ -____ -_____
Home Phone #:_____________________________ Cell Phone #:________________________________
Mailing Address: _______________________________________________________________________
(Street)
(City) (State) (Zip
Email Address: ____________________________________________________________
Ethnic Identity (Check the box that applies to you):
___ American Indian/Alaska Native ___Asian ___Black/ African American ___Hispanic/ Latino ___White
___Native Hawaiian/ other Pacific Islander ___More than one race reported ___No response /unknown
Financial Aid:
Have you applied for Financial Aid for the current school year? ___Yes ___No
What type of Financial Aid are you receiving? ____Scholarship _____Veteran’s ______Loan _____Grant
_____Other ______No assistance
How did you hear about us? _______________________________________________________________
What is your current enrollment status here at Penn Valley Community College?
___FT (12+hrs) ___PT (6-11hrs) ___Day student ___Evening Student ___Weekend Student
Career Interest: ____________________________________
Degree Plan: ____________________________________
My target to receive the following degrees:
___Associate’s ____Bachelor’s ____Master’s ____ Doctorate
___ Professional

First Generation Verification: Did either of your parents graduate from a four year university? __ Yes __No
Disability Verification:
Please identify any physical or learning disabilities that limit your participation in the educational experiences and opportunities offered by Metropolitan Community College.
_____________________________________________________________________________
_____________________________________________________________________________
Note: Documentation of your disability is required. Disability documentation for MCC-Penn Valley students is retained in confidential files in the Disability Support Services, HU 001
Income Verification:
Yes No
____ ____ Were you born before January 1, 1992?
____ ____ Are you married?
____ ____ Do you have children who receive more than half of their support from you?
____ ____ Do you have legal dependents (other than your children or spouse) who live you and receive more than half of their support from you?
____ ____ Are you a veteran of the U.S. Armed Forces?
____ ____ Are both of your parents deceased, or are you a ward/dependent of the court (or were you until age 18)?
Release Information
I certify that the information I have provided on this application is, to the best of my knowledge, complete and accurate. Furthermore, I understand that by applying for the Project Success Program, I authorize Project
Success staff to obtain records and/or data pertinent to my participation from other sources, including Disability
Support Services, and to release information to the United States Department of Education TRIO programs. The
Project Success staff also has my permission to communicate verbally or otherwise with staff, faculty, and/or off-campus professionals on my behalf.
Student Signature __________________________________ Date _____________________
If you checked “No” to all of the above questions, provide the following information
:
What was your parent or legal guardian’s taxable income for 2014?
__________
What was your taxable income for 2014?
What is the number of people living in the household?
__________
__________
If you checked “Yes” to at least one question, provide the following information :
What was your taxable income for 2014? __________
What was your spouse’s taxable income (if applicable)?
__________
How many people are in your household? Include yourself, your spouse, and any dependents.
Sources of income:
__________