STEM/Health Sciences Program Application TRiO Student Support Services is a U.S. Department of Education federally funded grant program. Please answer all questions completely. Please feel free to contact us at (831) 582-4451 with any questions you may have. This and all information you submit to this program will be kept confidential. Name: _________________________________________________________________________________________________ Last First Middle SSN: ______________________________________ CSUMB ID: ______________________________________ Date of Birth (MM/DD/YY): ___________________________ Gender (circle): Male or Female Address: ___________________________________________ Street (Apt/Space #) ________________________________________ City State Zip Code Cell Phone # ___________________________________ 1st semester at CSUMB: _________________________ Email _________________________________________ Are you a transfer student: YES NO Current grade level: ____________________ Major (or field of study): _____________________________________________ Ethnic and Race Identification (as defined by the U.S. Department of Education) 1.) Are you Hispanic/Latino? (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) YES NO 2.) Indicate one or more races that apply among the following: American Indian/Alaskan Native (A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.) Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.) Black or African American (A person having origins in any of the black racial groups of Africa.) Native Hawaiian or Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) More than one Ethnic group (If you are from more than one ethnic group, please check all boxes that apply.) Citizenship: US Citizen or National Permanent Resident/Other (must meet the residency requirements for Federal student aid/FAFSA) First-Generation: Father has a bachelor’s degree YES NO Mother has a bachelor’s degree Disabilities: Do you have any of the following documented disabilities? Physical Learning YES Medical NO NONE Foster Care Students (youth and/or adults who are in foster care or are aging out of the foster care system) 1.) Are you a current or former foster care youth/adult? YES NO 2.) Do either of your natural or adoptive parents have a bachelor’s degree? YES NO (If yes, which parent?____) 3.) Housing: Are you an individual who lacks a fixed, regular, and adequate nighttime residence? Low-Income To help us determine low income eligibility, you must provide one of the following: (A) If Dependent or Independent, a signed Student Income Verification Form (attached); (B) Verification from another governmental source; (C) A copy of your FAFSA Student Aid Report (SAR); or (D) A signed income tax form. Complete other side→ YES NO Have you previously participated or received services from any of the following programs? Educational Talent Search- TRiO ETS Extended Opportunity Programs and Services (EOPS) Student Disability Resources (SDR) Upward Bound- TRiO UB Other (GEAR-UP, AVID, ESL/ELL, etc):___________________________________________________________ What services are you interested in receiving or do you consider an immediate need? (Check all that apply) Academic Tutoring Academic Advising Financial Aid Financial and Economic Literacy Graduate and Professional Programs Counseling and Mentorship Career Exploration Enrichment Events Supportive Environment Internship and Research Support Services to enable students to complete postsecondary courses, which may include instruction in reading, writing, study skills, mathematics, science, and other subjects. Advice and assistance in postsecondary (college) course selection. Information on both the full range of Federal student financial aid programs and benefits (including Federal Pell Grant awards and loan forgiveness) and resources for locating public and private scholarships; and assistance in completing financial aid applications, including the Free Application for Federal Student Aid. Education or counseling services designed to improve the financial and economic literacy of students, including financial planning for postsecondary education. Activities designed to assist students in applying for admission to, and obtaining financial assistance for enrollment in, graduate and professional programs. Individualized counseling for personal, career, and academic matters provided by assigned counselors. Information, activities, and instruction designed to acquaint students participating in the project with the range of career options available to the students. Exposure to cultural events and academic programs not usually available to disadvantaged students. An institutional climate supportive of the success of students who are limited English proficient, students from groups that are traditionally underrepresented in postsecondary education, individuals with disabilities, homeless children and youth, foster care youth, or other disconnected students. Services to assist the student in exploring and/or preparing for appropriate internship and research opportunities For questions below, type and attach your responses if necessary: 1. Do your college and/or high school grades reflect your academic ability and potential? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 2. Please describe the level of commitment and motivation you have towards your academic success? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 3. What personal, academic, and/or other obstacles do you believe may prevent you from succeeding in college? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 4. Why would you like to be a participant of TRiO STEM/HS Student Support Services? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ All of the information provided by me or any other person on this form is true and complete to the best of my knowledge. I agree to provide proof of the information that I have given on this form, if I am asked to do so. I give my full authorization to TRiO SSS staff members to gather information from various departments to determine my eligibility for the program and its services. I understand that if I am selected as a TRiO SSS participant I will be required to be an active participant as deemed necessary for my academic success. Signature: _______________________________________________ Date: ___________________ The legislative requirements for all Federal TRIO Programs can be found in the Higher Education Act of 1965, as amended; Title IV, Part A, Subpart 2, Chapter 1, Sec. 402D; 20 U.S.C. 1070a-14. TRIO SSS STEM is 100% federally funded at $220,000 annually.