TRiO Student Support Services Application Personal InformationWhat campus will you be attending classes?* Blackwood Camden Name* First Middle Initial Last Street Address* Apartment # City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip* Student Email* Home PhoneCell Phone*Social Security #* Student ID* Gender* Male Female Birthdate* Age Citizenship / Ethnic / Racial GroupAre you a U.S. Citizen?* Yes No Martial Status* Single Married Separated Divorced Widowed If you are not a U.S. Citizen, are you a Permanent Resident?* Yes No Enter Permanent Resident Alien Number Please check race group which you think best applies to you.* American Indian/Alaska Native Asian Black or African-American Native Hawaiian/Pacific Islander White More than one Race Ethnicity Unknown Other I prefer not to disclose Are you Hispanic or Latino?* Yes No Have you ever participated in another TRIO program? (Check all that apply.) Upward Bound Talent Search EOC SSS McNair Scholars Are you a part of the Educational Opportunity Fund (EOF) Program?* Yes No EducationHave you or will you graduate from high school?* Yes No Did you receive a GED?* Yes No Year you received your GED* What High School did/will you graduate from?* Previous College(s) Attended When did you begin coursework at Camden County College?* Fall Spring Summer Year* When do you expect to graduate?* Fall Spring Summer Year* What is your current classification?* Freshman Sophomore What is your current GPA?* Enrollment Status?* Full-time Part-time Hours Enrolled* What is your major?* Do your parent(s) or legal guardian have a bachelor’s degree? Yes No Who has a bachelor’s degree?* Mother Father Both Have you ever been in foster care or in a court appointed guardianship?* Yes No If yes, were you in foster care after the age of 13 years-old?* Yes No Financial InformationWhat is the total number of persons in your family?*Did you or your parent(s) file taxes last year?* Yes No Check the range that includes your household income for last year* $ 0 - $19,320 $19,321 - $26,130 $26,131 - $32,940 $32,941 - $39,750 $39,751 - $46,560 $46,561 - $53,370 $53,371 - $60,180 $60,181 - $66,990 Over $66,991 I certify that the information entered here in this section is true and correct to the best of my knowledge.*Date* Student ContractIt is expected that each student participating in the program will be dedicated to academic excellence. With my signature, I agree to the following: Meet with my Success Coach a minimum of two times during the semester (at least once in person). Attend a minimum of one Student Success Workshop, SSS activity and/or cultural educational activity per semester. If I am on academic probation or receive an early alert, I agree to contact SSS to set up an academic plan of action. I agree to work towards achieving the goals outlined in my Individual Academic Plan (IAP) Comply with all rules and guidelines in order to remain eligible in the SSS program provided by College. Student ConsentI authorize Student Success Programs staff to access any records required in assisting me including, but not limited to: Disability Services Registrar’s Office/Student Records Financial Aid Office Faculty members regarding academic progress I agree to have my photo used to promote the program. (note: acceptance is not contingent upon agreement) I certify that the information included on this application is true and correct to the best of my knowledge. If additional documentation is required, I agree to submit required documentation in a timely manner. I understand that if found that I have intentionally misrepresented myself, it is sufficient cause for dismissal from the Student Support Services Program.Signature*Date* CAPTCHACommentsThis field is for validation purposes and should be left unchanged.