Rev: 06/29/2012
CURE-SSS-STEM
Participant Application
University of Central Oklahoma
TRIO Student Support Services
100 North University Drive
Room 315 A, Box 82
Edmond, OK 73034
(405) 974-3607 Office / (405) 974-3855 Fax
Trio Student Support Services (SSS) is a federal program funded by a grant from the Department of Education. The purpose of Trio
SSS is to support participants in achieving academic success. Students are accepted to the Trio SSS program based on academic need
(page 3), eligibility criteria (page 2), and space availability. To determine your qualification for the program, please fill out the
following application completely and accurately. The information you provide is strictly confidential. Completion of this application
does not guarantee acceptance into Trio SSS.
TRIO / SSS Application Checklist:
Complete this application
Current Income Tax Return (Parents’ income tax if dependent, Student’s income tax if recognized as an
independent with financial aid, Personal Statement of Non-Filing, or TANF information).
Transcript Class Schedule Financial Aid Award Letter Student Aid Report Income Tax Documents
Students qualify for the TRIO / SSS program by meeting at least one of the following:



Low-income student (family meets Federal Government Income Eligibility Guidelines and verified by UCO)
First-generation college student (signifies that parent(s) did not graduate from a four-year institution)
College student with documented disabilities
In addition, ALL TRIO / SSS participants must:



Be undergraduate students accepted or enrolled at the University of Central Oklahoma
Be U.S. Citizens or permanent residents
Demonstrate academic need for Trio/SSS program services
Selection Process: When there is limited space in the TRIO / SSS program, priority will be given to:



Students who are both income-eligible and first generation college students
Students who are both income-eligible and have disabilities who require educational accommodation
Alumni of other TRIO programs: Upward Bound, Educational Talent Search, Educational Opportunity Center, other Student
Support Services
MOST IMPORTANTLY, students MOTIVATED to make full use of TRIO / SSS services to become a successful UCO College
graduate. It is expected that participants meet with a TRIO/SSS advisor and engage in one workshop per month, one cultural
activity per semester, and one hour of study hall per week.
Personal Information
Student ID # *___________________________
Name (first, middle, last): ____________________________________SSN:___________________________
Address: ________________________________ City: ________________________ Zip Code: ___________
Preferred
Telephone: _______________________ UCO Email: ____________________________ DOB: ___ /___ /___
Ethnic Origin:
Gender:
Male
Marital Status:
aiian or other Pacific Islander
or Caucasian
Number of dependents/children _________________
Citizenship:
_____________________
If applicable, please include a
copy (front & back) of your
I-90 card.
Rev: 06/29/2012
First Generation Eligibility Information
Did your mother earn a 4-year degree?
Yes No Unknown 
Did your father earn a 4-year degree? 
Yes No Unknown 
With whom did you primarily live with before your 18th birthday?
Mother
Father
Both
Ward of the State Other:___________________________
Do you have a documented physical, mental or learning disability? Yes No
Do you receive assistance from: Disability Support Services Vocational Rehabilitation NA
Have you completed the FAFSA? Yes No
Do you receive a Pell Grant? Yes No Unknown
Have you previously participated in a TRIO program: SSS UB TS EOC No
Federal TRIO Programs
2012 Annual Low Income Levels
Taxable Income Levels
(Taxable Income is your income after deductions, NOT your gross income.)
Size of Family unit
48 Contiguous States,
D.C., and Outlying Jurisdictions
1
$16,755
2
$22,695
3
$28,635
4
$34,575
5
$40,515
6
$46,455
7
$52,395
8
$58,335
For family units with more than eight members, add the following amount for each additional family member: $5,940 for the 48
contiguous states.
This information was retrieved from: http://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html
Income Eligibility by Family Member
Our family income is at or below the levels indicated above for our family size.
This information is verified by my parent’s signature if dependent, and my signature if independent on the tax return.
Our family income exceeds the levels indicated above for our family size.
Please indicate family/household annual Taxable Income for last year $________________
Number in household claimed on your (or your parent’s) last year Income Tax Form (including yourself) _____
(If your parent’s did not file taxes, please supply a personal statement attached to the application.)
 I am considered an independent student or a ward of the court and did not file taxes. This is recognized by the UCO office of
Financial Aid. I will also provide a personal statement attached to this application.
Educational Information
Do you plan to transfer to another 4 year institution? No Undecided Yes, before UCO graduation
Major: _________________________________ GPA: ____________________
Are you a transfer student? No Yes Have you been out of school more than five years?No Yes
If no, please indicate High School attended_________________________________
ACT/SAT Score ____________________ Have you completed a Bachelor’s Degree? No Yes
Rev: 06/29/2012
Academic Need
THIS IS NOT A SCHOLARSHIP PROGRAM. Federal regulations require that all participants in TRIO/SSS demonstrate
academic need for program services. All TRIO/SSS participants are expected to meet with a TRIO/SSS advisor or engage in other
TRIO/SSS activities at least once workshop per month, one cultural activity per semester, and one hour of study hall per
week during the academic year.
TRIO/SSS offers assistance in the following areas, if accepted what services are you most likely to use?
□ Academic Advising (Course selection/registration, long-term planning)
□ Financial Aid Counseling (award letter evaluation)
□ Academic Counseling (goal-setting, progress monitoring)
□ Study Skills Development (workshops or individual)
□ Career Counseling (career goal planning, employment)
□ Time/Stress Management
□ Major coursework grade improvement
□ Improve overall college grades
□ Other; please state specific areas in which you would like assistance
Please answer the following questions about yourself. This information will help us to better understand and assess your needs.
Briefly, what are your educational goals?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Briefly, why is attending college important to you?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
FOR OFFICE USE ONLY:
FG 

LI
LIFG 
D 
LID 
N/A 
Rev: 06/29/2012
Consent for Release of Photographs and Personal Info
I hereby give permission for the University of Central Oklahoma, Student Support Services to take my picture as part of my
participation in the program. I understand that this picture may be published and used in all types of public relations related activities
in which the program may be involved. I understand that my picture may be published along with any related information about
myself that is appropriate to the activity.
I agree with these terms
I disagree with these terms
Consent for Release with Academic Records
I hereby give permission for the University of Central Oklahoma, Student Support Services Program to obtain any and all of my
academic records, including college transcripts, test scores and records, teacher evaluations, financial aid information and any and all
future college transcripts and records.
I understand that these records will only be used internally by the program and on an individual basis. I also understand that records
compiled on a group basis may include any and all of these records. I also understand that the compiled information will be used to
determine my eligibility for the program, program evaluations, performance reports, and any related uses.
I agree with these terms
I disagree with these terms
Contractual Agreement
I accept the offer to participate in the Student Support Services (SSS) program at the University of Central Oklahoma. I understand
that the purpose of this program is to provide academic support for the first generation or financially qualified students with academic
potential to successfully complete their undergraduate degree at the University of Central Oklahoma. I further understand that this
opportunity is intended to give me the guidance needed to complete my four year degree plan.
I realize that I will be expected to give my full commitment to the Student Support Services Program and to satisfy the following
program criteria to maintain an active status. (Please initial below)
________
Utilize tutoring on an ongoing basis as needed and meet with tutor as scheduled
________
Attend one scheduled program workshop per month
________
Attend one scheduled program cultural activity per semester
________
Cooperate with follow-up surveys, etc.
________
Strive to improve GPA
________
Meet with the SSS staff for semester retention meetings
________
Notify SSS of potential conflicts that may hinder my graduation from UCO
________
Notify SSS program staff of any changes in enrollment status, GPA, permanent or local mailing address, phone
number or email address. I will also notify SSS of scholarship and academic awards I have received, graduate
programs to which I have applied, accepted or enrolled.
I have read and agreed to the conditions for acceptance in the Student Support Services Program. I understand that at the conclusion
of each regular semester, the SSS staff will discuss my eligibility to continue in the program. I realize that failure to comply with any
of the above conditions will affect my eligibility. Furthermore, I understand that failure to remain active in the program (i.e. tutoring,
attendance at workshops and cultural events) may result in my dismissal from the program.
________________________________
Student Signature
_______________________________
Staff Signature
______________
Date