TRiO SSS STEM-HS Application

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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.
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