TRIO Student Support Services Application: Polytechnic

Campus and Program

Downtown

Polytechnic

Tempe

West-STEM

Applying for

Spring 2020

Summer 2020

Fall 2020

Personal Data

Full Name

ASU Affiliate ID

Local Street Address

City

State

Zip

Home Phone

Cell Phone

ASU Email

Eligibility

I am a

United States Citizen

National, permanent resident*

Have INS Documentation*

* Please provide a copy of documentation

I am currently enrolled in an ASU Polytechnic undergraduate program, seeking my first baccalaureate degree.

Select all that apply

I am a “first generation” college student – neither of my parents graduated from a 4-year institution

My household meets the federal government’s guidelines for low income.

I am registered with the Disability Resource Center (DRC) and hereby authorize DRC to release records and/or information from my file regarding my disability.

I hereby apply for services in the TRIO Student Support Services Program. I certify that all information supplied by me is correct. I give permission to the TRIO Student Support Services Program staff to check my financial aid and/or I will provide financial information. I give consent for my information, including my name, picture, graduate status, college, major and any awards or scholarships that I receive to be used by the TRIO staff in publications or ASU display cases to promote the success of TRIO students. I authorize the release of my student academic and financial aid records for the program director to use for reporting purposes to the Department of Education.

Student Signature

Date

“**TRIO Eligibility/Enrollment Forms are active for one academic year ONLY.

OFFICE USE ONLY

Status of Application

Accepted Date: ______

Denied Date: ______

Waitlist Date: ______

Waitlist due to

Eligibility Type
Not Eligible
Incomplete Application
Lack of space in the program to serve the student

Accepted as

FG/LI Type
FG ONLY
LI ONLY
DIS/LI
DIS ONLY

Academic support needs ______________________________________________
Obstacles to Education ________________________________________________
Total _________________________________________________________________

Director Signature: _____________________________________________________