Rio Hondo MESA/TRiO SSS STEM Application
This application is to be typed. The file can be saved to your computer and printed after it is completed.
Social Security Number:_________________________________
Student ID:_______________________________
First Name: ________________________________ Middle (or initial): _____________ Last Name: ____________________________________
Current Address/Mailing Address ________________________________________________________________________________
City: ___________________________________________________________
State: __________________Zip: _____________________
Permanent Address (if different):: _____________________________________________
Cell Phone: __________________
Home Phone: _____________________Work Phone: ______________________
Preferred E-mail: _____________________________________________ Email in RHC system:
Birthdate: ________________
Gender:
Choose one
Are you a Veteran?
Choose One
(mm/dd/yyyy)
Ethnicity (Check all that apply):
American Indian or Alaskan
Black or African American
White
Hispanic or Latino
Native Hawaian/Pacific Islander
Asian
Is a language other than English spoken regularly at home?
Residential Status: Choose one
Resident Alien #
(Attache copy)
Choose One
If yes, specify:
RHC Major:
_____________________________________
Transfer Major:
_____________________________________
When did you first enroll at this college:
Semester
Year
Choose one
What was your first college:
Math Class _______________________
Intended Transfer College(s) –
in order of preference:
English Class________________________
1. ________________________________
Obstacles that may interfere with your
educational goal (check all that apply):
2. ________________________________
Current College Counselor:
 Grades
 Financial need
 Employment issues
 Family obligations
 Knowledge of educational system
 Exceptional needs (specify below)
3. ________________________________
Total number of college units completed:
Prospective date of transfer:
30-60
Semester
Previous College: _____________________
Dates: __________________________
GPA: __________________________
Do you have a degree?
BA/BS
Year
Previous school(s) attended:
Current college GPA:
AA/AS
______ _____
Choose one
Choose One
Choose One
Are you employed? Choose One
If yes, how many hours per week?
Occupation: _______________________
Choose One
Choose One
Did you file a FAFSA? Do
you receive BOGW? Do you
receive Pell Grant?
Choose One
High School:_________________________
Grad Date: ________________________
GPA:_______________________________
Are you in EOP&S
Choose One
Another TRiO Program Choose One
Who do you currently live with?
Choose one
Which parent did you regularly reside with and receive support from during your childhood?
Choose one
Highest level of education acheved by each of your
parents/guardians:
Father:
Mother:
Type of work your parents or guardian have done over the
past years or prior to retiring:
Choose One
Father:
Choose One
Mother:
Other:
Other:
Choose One
Other:
Choose One
Other:
FINANCIAL INFORMATION
Name: ____________________________________________
Student ID: ____________________________________
STEP 1: Answer the following questions about yourself if you (the student) are less than 24 years old. Otherwise skip to Step 2.
a. Are you married
Choose One
b.
c.
d.
e.
f.
Do you have children or other dependents (other than a spouse) who receive more than half of their
support from you?
Choose One
At any time since reaching 13 years of age, where you an orphan, in foster care or a ward of the
court?
Prior to reaching 18 years of age, were you an emancipated minor or did you have a court-appointed
legal guardian?
Are you serving on active duty (for other than training purposes) in the U.S. Armed Forces?
g.
Are you an U.S. Armed Forces veteran who was on active duty & was released under a condition
other than dishonorable?
Are you in college and currently working on a master’s , professional or doctoral degree?
h.
Are you less than 18 years of age and have no parent or guardian?
i.
Are you homeless (i.e., you lack a fixed, regular & adequate nighttime residence) or are you at risk
of becoming homeless?
Choose One
Choose One
Choose One
Choose One
Choose One
Choose One
STEP 2: You must answer the following questions about yourself if you are at least 24 years old or you answered YES to any
question in STEP 1 . Your parent(s) must answer the following questions about themselves if you are less than 24 years old and
you answered NO to all questions in STEP 1.
a. What is the total number of persons (including you) in your family? (Exemptions claimed on tax return lind 6d)
b.
 Taxable income for 20____ calendar
year was: (last calendar year)
Parent
Adjusted Gross Income (1040 line 37,
1040A line 21, 1040EZ line 4)
Taxable income (1040 line 43,
1040A line 27, 1040EZ line 6
 Our family did not file a federal income tax
return for the last calendar year. My family’s
$
total income from last calendar year was:
Student
$
$
$
$
 Our family had no taxable income during the last calendar year.
STEP 3: Please read the following statement and then sign and date below. If you (the student) are less than 24 years old and
answered NO to all questions in STEP 1, your parent or legal guardian must also read the following statement and then sign and
date below it.
By signing this application, I (we) attest that all the information on this application is true.
Moreover, I authorize the release of the student’s official academic records, information about performance from instructors,
colleges and testing agencies, financial aid and other offices to determine eligibility to the MESA/TRiO SSS STEM Program,
understanding that the information in these records will only be used to assess the student’s need for program services, discern
the student’s educational progress, evaluate the effectiveness of program activities, and fulfill program-reporting
requirements. You may be asked to provide additional information for eligibility determination.
I give my permission for MESA to give my name to college and employer representatives, and to use my photograph
in MESA/TRiO SSS STEM and college promotional materials
 Yes
 No
Student Signature
Signature of Parent or Legal Guardian
Date
Print Parent Name
NAME
Academic History
List all the Math and Science courses you have taken most recently or are currently taking at Rio Hondo College and at
others colleges you have attended. Include the name of the other college/s you took the course (if applicable) and
attach an unofficial transcript.
College Math & Sciences Courses
Final Grade or CE
for currently
enrolled
Number of
times taken
List the highest level Math and Science course you completed as a high school student.
High School Math & Sciences Courses
Final Grade
List all the courses that you are enrolled in during the current semester:
Application Checklist:
MAKE SURE ALL THESE DOCUMENTS ARE SUBMITTED.
MESA/TRiO SSS STEM Application:
Student Signature on page 2
Parent Signature on page 2 (if you are under 24 years old)
Article of Commitment with initials
Personal Statement
Supporting documents:
Previous year's tax forms pages 1 and 2
Unofficial transcripts for all colleges attended
Copy of Green Card if applicable
Federal tax transcript on https://sa2.www4.irs.gov/irfof-tra/start.do (Date ordered: ___________)
Form Version March 2015
Article of Commitment
By applying to MESA/TRIO, you are seeking to become part of a highly motivated and dedicated
community of students and support staff. Your initials next to each item indicate your agreement
to the statement. On the next page, you will be asked to write a brief reflection on these items, so
you are advised to read this page carefully.
I agree to be a part of the MESA/TRIO COMMUNITY. Students who benefit most from their experience in
MESA/TRIO are students who develop close connections with their peers and program staff. We, and most especially
your peers, are here to encourage and support you in realizing your goals of graduation and transfer from Rio Hondo
College. Being part of the MESA/TRIO community includes, forming study groups with your peers, keeping appointments, reading
and responding to emails, responding to telephone calls, and keeping program staff aware of any personal or academic obstacles that
are preventing your success.
I agree to be an ACTIVE AND ENGAGED LEARNER, both inside and outside of my classes. As a MESA/TRIO
student, you are asked to be engaged in all your classes—showing up on time, notifying instructors of an absence, taking
notes, reading material before class, and submitting assignments on time. You are also expected to engage with your
instructors during their office hours. Office hours are a great time to get to know your instructors in a different way, and receive
one-on-one help from an expert (your instructor).
I agree to participate in the NEW STUDENT ORIENTATION, and/ or enroll in MATH 049-INTRODUCTION TO
MESA. The NEW STUDENT ORIENTATION provides a detailed overview of the benefits and services available to you as a
MESA/TRIO student. MATH 049 will introduce you to STEM career paths, transfer requirements, summer programs,
and scholarships. Both the orientation and MATH 049 are intended to equip you with information to help you realize
your goal of graduating and transferring from Rio Hondo College. Program staff will recommend you to enroll in MATH 049, and/
or participate in the NEW STUDENT ORIENTATION.
I agree to attend ACADEMIC EXCELLENCE WORKSHOPS (AEWs). AEWS are intended to reinforce material you
are learning in your mathematics and science courses. The AEW environment is centered on group work, asking
questions, and learning from each other. You are required to attend AEWs associated with your courses. Students who
regularly attend AEWs are more successful in their courses. Depending on your course, AEWs meet one to two times a week, for
about 90-minutes to 2 hours a session. An AEW schedule will be provided.
I agree to maintain an updated EDUCATIONAL PLAN (ED PLAN). Having an ED PLAN takes the guess work out of
registering for classes. With the MESA/TRIO counselor, you will craft an ED PLAN detailing courses needed to graduate
and transfer from Rio Hondo College. Your ED PLAN will be personalized based on your academic history and life
situation. You are required to follow your ED PLAN and inform program staff of any issues or questions. You must meet with
program staff once a semester to ensure that you are on track.
I agree to attend MESA HOUR. MESA HOUR is a series of informational meetings that cover a range of topics, such
as: study and time management skills, transfer information, summer internship and research program information, and
much more. MESA HOUR also provides opportunities to network with professors and industry professionals in casual
settings. MESA HOUR is on select Thursdays, 1:00 PM, a schedule will be provided.
I agree to maintain an updated GRADE TRACKER and submit a copy when required. The GRADE TRACKER is
helps you to track your academic progress throughout the semester. On your GRADE TRACKER, you are to account for
scores you earn on all exams, quizzes, homework, and any other assignments required in your courses. You must keep
your GRADE TRACKER updated throughout the semester. At least once during the semester, we will require you to submit a copy of
your GRADE TRACKER.
Personal Statement
As you may have gathered from your careful reading of the previous page, being a STEM major and
participant in MESA/TRIO is a serious commitment of time and energy. With that said, being a
participant in MESA/TRIO is a commitment that, if utilized to its fullest extent, will help you realize your
goals for education and career.
Your initials to all eight of the statements on the Article of Commitment collectively represent your agreement to utilize the MESA/TRIO
programs to their fullest extent. Please write two personal statements on the following prompts. These questions ask you to reflect on the
services and expectations of MESA/TRIO in relation to how they will impact your life. Please be honest in responses. Responses to each
prompt must be at least 150 words and should be no more than 300.
Prompt 1
• How do you envision the services and expectations of MESA/TRIO helping you as you work toward realizing your goals?
• What aspects of this agreement most excite you?
Prompt 2
• How do you envision it being difficult to participate in the services and meet the expectations of MESA/TRIO?
• What aspects of this agreement are you apprehensive about?
Please briefly describe any obstacles you foresee preventing your success as a college student. These
obstacles may relate to your personal life, financial situation, and/ or academic preparation.