TRiO Student Support Services Interest Form

PART 1: PERSONAL DATA

First Name

Middle Name

Last Name

Birthdate

Are you a US Citizen?

Yes

No

Are you a Permanent Resident?

Yes

No

Green Card #

PART 2: ETHNIC/RACIAL BACKGROUND INFORMATION

Are you Hispanic?

Yes

No

Race (please select all that apply)

The information requested on race, ethnicity and sex is not used in the selection process. It is set aside and used in reports to the Department of Education in Washington D.C. It is the policy of the Student Support Services program not to discriminate on the basis of sex, race, religion, color, national origin, age and disability in its decisions.

PART 3: STUDENT CONTACT INFORMATION

Home Phone:

Student Cell Phone:

Saint Peter's Student Email Address

Saint Peter's Student/Spirit ID:

Mailing Address

Country

Street

City

Region

Postal Code

PART 4: TRIO STUDENT SUPPORT SERVICES PROGRAM ELIGIBILITY & VERIFICATION (REQUIRED)

Have you ever participated in: (check any that apply)

Are you a current SPU student (completed at least one semester at SPU)?

Yes

No

Are you an incoming first-year student (Have not attended college)?

Yes

No

Are you a Transfer Student?

Yes

No

Name of Institution:

Are you a high school graduate?

Yes

No

Name of High School:

First Generation Verification - The term “first-generation college student” means:

1. An individual both of whose parents did not complete a baccalaureate (bachelor’s or 4-year college) degree, or

2. In the case of any individual who regularly resided with and received support from only one parent, an individual whose only such parent did not complete a baccalaureate (bachelor’s or 4-year college) degree.

Are you a “First Generation College Student”?

Yes

No

Disabilities Verification - A person who has a disability, as that term is defined in section 12102 of the Americans with Disabilities Act (42 U.S.C. 12101 et seq.).

Do you have any documented physical and/or learning disabilities?

Yes

No

Is the disability information on file with Saint Peter’s University Disability Services?

Yes

No

Income Verification - TRiO Legislation §1070a-11 Program Authority; authorization of appropriations (e) Documentation of status as a low-income individual (1) Except in the case of an individual’s status pursuant to subsection (h) (4) shall be made by providing the Secretary with – (A) a signed statement from the individual’s parent or legal guardian; (B) verification from another governmental source; (C) a signed financial aid application; or (D) a signed United States or Puerto Rico income tax return. Please be advised by filling out this section and signing the program application on page 2, this document will serve as your statement, as in (A).

1. Please indicate family/household annual Taxable Income from your 2022 tax return

Taxable Income is found on Line 43 on a 1040 return and Line 27 on a 1040A return.

2. Number in household claimed on your last year IRS Income Tax Form (including yourself):

Federal TRIO Programs Current-Year Low-Income Levels (Effective January 19, 2023 until further notice)
Size of Family Unit	48 Contiguous States, D.C., and Outlying Jurisdictions	For family units with more than eight members, add the following amount for each additional family member: $7,710 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $9,645 for Alaska; and $8,865 for Hawaii.
1	$21,870
2	$29,580
3	$37,290
4	$45,000
5	$52,710
6	$60,420
7	$68,130
8	$75,840

PART 5: RELEASE OF RECORDS & PARTICIPANT AGREEMENT

AUTHORIZATION FOR RELEASE OF RECORDS:

Yes

No

Please enter your initials:

(For duration of Program Participation)
I hereby voluntarily grant permission to TRiO SSS, to extract additional personal information data from authorized Saint Peter’s University databases. Specifically, I authorize disclosure of the following information or category of information – semester schedules, financial aid, program eligibility verification, transcripts, disciplinary actions, individual education plans, and course attendance history for the purposes of evaluating eligibility for admission and participation. Data platforms include but are not limited to, Slate, Colleague, NJ FAMS, HESAA, and the Office of Financial.

PHOTO & MEDIA RELEASE:

Yes

No

Please enter your initials:

I give Saint Peter’s University and the TRiO Students Support Services Program, permission to record the image and/or voice of myself as named. I grant Saint Peter’s University all rights to use sound, still, or moving images in any medium for educational, promotional, advertising, or other purposes that support the mission of the university.

STUDENT CONTRACTUAL AGREEMENT:

Yes

No

Please enter your initials:

If selected, upon my acceptance to the TRiO Student Support Services program, I agree to fulfill all my requirements as a program Scholar and be committed to my academic and personal achievement at Saint Peter’s University. I also agree to the following:

Complete placement testing and attend Peacock Prep (Pre-orientation) in order to enroll in Summer Academy. (NOTE: Students will receive placement testing and Peacock Prep information once Admissions receives Intent to Enroll and tuition deposit ($150).

Complete TRiO SSS, 3-credit Summer Academy which is mandatory, and critical to my successful enrollment in the fall semester. (Applicable to incoming first-year TRIO scholars only)

I will be placed in Student Support Services designated 1 credit courses and a supplementary study/learning lab throughout my collegiate career.

Meet with my Student Support Services advisor on a regular basis, and as required, during the fall and spring semester throughout my academic career at SPU, to review my progress. Accept referrals for tutoring and or counseling because these are the resources that will help me succeed.

Familiarize myself with University policies, important deadlines and student expectations.I accept responsibility for acquainting myself with registration, withdrawal, and refund policies and procedures set forth in  the current Saint Peter’s University Catalog and Schedule (www.saintpeters.edu)

I agree to participate in the Student Support Services Program classes, services, research and other activities as scheduled by the Director of the Saint Peter's University, Student Support Services Program.

I understand that the student contractual agreement is subject to change at the discretion of the TRiO SSS Program. Upon official acceptance into the program, the staff and I will review the contractual agreement and clarify the meaning of the contract. Both parties will sign the contract.

APPLICATION CERTIFICATION & AUTHORIZATION:

I, hereby certify that all answers and information provided, constitute a full and complete disclosure with respect to this application. I understand that this application is being made in connection with the receipt of federal funds, and that the U.S. Federal Government and the U.S. Department of Education may verify this information. Any misrepresentation of facts provided on this application will result in nullification of my application prior to admission.

Applicant Signature (please type your full name):

Please enter today's date

TRiO Student Support Services Interest Form

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