Lourdes University
TRiO/STUDENT SUPPORT SERVICES
Program Application
S T U D E N T S UPPORT SERV I CES
Lourdes University’s TRiO program is committed to providing students with personal attention to their academic, cultural, and
social needs.
Name_______________________________________________________________________________________________________
(last) (first) (middle initial)
Date _____________________________________ Lourdes University ID # _____________________________________
Home Address ________________________________________________________________________________________________
Street/Apt. # City State Zip
Campus Address ______________________________________________________________________________________________
Street/Apt. # City State Zip
Home Phone #____________________________________ Cell phone #____________________________________________
Can we text you?  Yes  No
Student E-mail Address_________________________________________________________________________________________
Date of Birth ____ / ____ / ____
Gender  M
F
Marital Status  Single  Married
Veteran  Yes  No
What is your academic goal at Lourdes?  Associate Degree - Major: _______________________________
 Bachelor Degree - Major: ______________________________ Eligibility Criteria (X all that apply)
 Undecided
What is your current Lourdes University status?
 US Citizen or permanent legal resident
 New student
 First Generation (neither parent has a bachelor’s degree)
 New transfer student
 Qualifying income level (see chart on page 3)
 Documented Disability
***If you have a documented disability, please contact the
Office of Accessibility Services - 419-824-3523
Are you registered:  Full time (12+ credits)  Part-time (<12 credits)
What year in college are you? (Record # of college credits you have earned to date in the appropriate space below)
_______ Freshman _______ Sophomore _______ Junior _______ Senior
VERIFICATION AND RELEASE INFORMATION
TRiO/Student Support Services is a program designed to help you graduate. The information provided is confidential and
will help determine eligibility for the TRiO program. Discrimination is prohibited on the basis of race, gender, color, national
origin, religion, age, disability, marital or parental status, or sexual orientation.
I hereby authorize TRiO/Student Support Services to share any information pertinent to my participation in the program.
This information includes, but is not limited to, financial aid information, standardized test scores, transcripts, and grade
reports. I also verify that the information provided on this form is correct and complete to the best of my knowledge.
Permission to contact professors/advisor:  Yes  No
Permission to release name for recognition (scholarships, etc.):  Yes  No
Permission to take my picture and use for recognition and advertising:  Yes  No
Student’s Signature_______________________________________________________ Date_______________________________
April 2016
Name ____________________________________________________ Date _________________ Reviewed Date _______________
TRiO Student Support Services Student Needs Assessment
This inventory will help in assessing your needs for services which are offered by the TRiO Program. Please check YES or NO in
response to each of the following questions.
YES
NO
1.
I would like to learn more about my individual learning style.
2. I would like to manage my time more efficiently.
___
___
___
___
3.
I would like to become a better test taker.
___
___
4.
I am interested in academic support/tutoring.
___
___
5.
I need to improve my study habits and skills.
___
___
6.
I need to improve my writing skills.
___
___
7.
I need to improve my math skills.
___
___
8.
I need to improve my reading skills.
___
___
9.
I am confused about where to start in choosing a career path.
___
___
10.
I want to learn which careers typically match my skills, interests,
and personality traits.______
11.
I am distracted by personal matters to the point that I am having
trouble studying/keeping up with assignments.______
12.
I feel uncomfortable communicating with professors/instructors,
staff, and other students.______
13. I would like to improve my technology/computer skills.
___
___
14.
I need assistance with the financial aid process.
___
___
15.
I would like to learn about disability services on campus.
___
___
16.
I would like to receive academic advising to prepare me for entry
into my major.______
17.
I need personal support and encouragement.
___
___
18.
I would like to learn more about cultural diversity.
___
___
19.
I would like to attend cultural activities e.g., museums, theater.
___
___
20.
I would like to participate in activities that benefit others.
___
___
21.
I would like to develop more leadership skills.
___
___
Please state how TRiO services can assist you in achieving your academic goals: ________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
April 2016
Student Income Verification Checklist
Name _____________________________________ Signature _____________________________________ Date ______________
1. Are you receiving financial aid for the current year?  Yes  No
(X all that apply)  Pell Grant
 Loans
 Scholarships
 Other
2. Documentation of Low Income Eligibility (need at least one)
 2015 1040 Income Tax Form
 Self-signed statement of low-income based on chart (see chart below)
Note: This is only to be used for students with no other way of documenting their low income eligibility
(e.g., did not file taxes, did not receive state assistance, and did not apply for financial aid)
I, ___________, certify that my taxable income for 2015 was below the qualifying income levels
(see income levels chart below).
 I understand that I am not accepted into the TRiO program or eligible for services until my application file is complete and I have been approved for admission per a letter from the TRiO Director.
 I understand that I must meet participant requirements in order to maintain my TRiO membership.
Federal TRiO Programs
2015 Low-Income Levels
(Effective January 25, 2016 until further notice)
Size of
Family Unit
48 Contiguous States, D.C.,
and Outlying Jurisdictions
Alaska
Hawaii
1
$17,820
$24,030
$30,240
$36,450
$42,660
$48,870
$55,095
$61,335
$22,260
$30,030
$37,800
$45,570
$53,340
$61,110
$68,880
$76,680
$20,505
$27,645
$34,785
$41,925
$49,065
$56,205
$63,345
$70,515
2
3
4
5
6
7
8
For family units with more than eight members, add the following amount for each additional family
member: $6,240 for the 48 contiguous states, the District of Columbia, and outlying jurisdictions; $7,800 for
Alaska; and $7,170 for Hawaii.
The term "low-income individual" means an individual whose family's taxable income for the preceding year
did not exceed 150 percent of the poverty level amount.
The figures shown under family income represent amounts equal to 150 percent of the family income
levels established by the Census Bureau for determining poverty status. The poverty guidelines were
published by the U.S. Department of Health and Human Services in the Federal Register on January 25, 2016.
Return to:
TRiO/SSS Staff at Lourdes University, St. Francis Hall
6832 Convent Blvd., Sylvania, OH 43560
419-824-3836 fax 419-824-3753
Why are you interested in TRiO?________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
How did you hear about TRiO?_________________________________________________________________________________
__________________________________________________________________________________________________________
April 2016