Kirkwood Community College
Student Support Services
Application for Program Participation
Learning Services
Department
2063 Cedar Hall
(319) 398-5574
Instructions: This form can be completed in Adobe Reader. The text fields
allow you to type your answers. When finished, print and return to:
Learning Services Office 2063 Cedar Hall.
PERSONAL INFORMATION
Name:
k#
(Last) (First) (MI)
Address:
Phone Number:
City:
Gender:
State:
Male
Female
Zip Code:
Email:
Date of Birth:
SSN:
Ethnicity:
Hispanic or Latino Black or African American Native Hawaiian or other Pacific Islander
American Indian or Native American
Are you a citizen or permanent resident of the U.S.A.?
Do you consider yourself any of the following:
Yes
ESL
White
Asian
No
Veteran Foster Child Homeless Dislocated Worker
EDUCATIONAL INFORMATION
OR
Graduated from High School (MM/YY):
Did not graduate high school OR obtain a GED
Received GED (MM/YY):
Are you a former participant of a TRiO Program? If so, which one
SSS
When did/will you first enroll at Kirkwood (Semester /Year):
Did you enter Kirkwood as: New from HS
Transfer student, from
UB
UBMS
Yes
TS
GU
No
EOC
Current Major:
Out of HS 1-4 years
Out of HS 5+ years
Do you plan to attend college?
Full-time (12+ credits) 3/4 time (9-11 credits)
1/2 time (6-8 credits) Less than 1/2 time (5 credits or less)
What is your academic goal at this time?
Do you plan to transfer to another institution?
Certificate
No, I do not plan to transfer
Associate of Arts (AA)
Yes, to a 4-year school after Kirkwood graduation
Associate of Science (AS)
Yes, to a 4-year school before Kirkwood graduation
Associate of Applied Science (AAS)
Undecided
The principal purpose for collecting all information on this application form is to administer the program, including tracking and evaluating participant
progress. Providing information is voluntary; the data will be retained in the program files and may be released to other Department of Education officials in the
performance of their official duties.
OVER
ELIGIBILITY INFORMATION
Check any of the criteria that apply:
Are you a first-generation college student? (Neither parent or guardian has a four-year college degree.) Do you have a disability? (i.e. physical, learning, mental health or other)
Yes
Yes
No
No
If yes, is the disability documentation on file with the Department of Learning Services?
Yes
No
Comment(s)
Do you consider yourself low-income?
Yes
No
*The term “low-income” means an individual whose family’s taxable income for the
preceding year did not exceed 150% of the poverty level amount. (Income will be verified
by SSS staff.)
Size of
family unit
Current year
low-income limits
1
$17,505
2
$23,595
3
$29,685
4
$35,775
5
$41,865
6
$47,955
7
$54,045
8
$60,135
NEEDS AND GOALS
Check the services or accommodations which you believe would benefit you here at Kirkwood Community College.
Skill Building
Tutoring
Testing Alternatives
Student Support
Academic Prep
Books on CD
Extended Time
Academic Advising
Basic Math
Group
Have Test Read
Career Workshops
Basic Writing
Peer
Quiet Room
Financial Aid Advising
College Prep
Job Seeking Skills
College Reading
Personal Counseling
Computer Skills
Transfer Counseling
Communication Skills
Writing Lab
How to be Successful in College
How did you first find out about TRiO SSS?
SIGNATURE FOR TRiO ACCESS AND SERVICES
I understand and give permission to SSS professional staff members to have access to information relevant to my academic
status: admissions data, registration information, transcripts and grades, financial-aid verification, disability documentation and
updates from faculty or staff. This information will be used to confirm my eligibility for SSS and, if a participant, on an ongoing
basis to confirm my progress and identify needs.
By signing below, I verify that all information provided on this application is true and accurate, and I grant Kirkwood
Community College Student Support Services permission as stated above.
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Student Signature
Date