Thank you for your interest in the TRIO Student Support Services- Traditional program at Kirkwood Community College!  Please complete this application as thoroughly as possible.  You cannot save and restart this application. If you have any questions, please call our office at (319) 398-5455.

Personal Information:
First Name *
Last Name *
Middle Name:
knumber: *
Date of Birth (MM/DD/YYYY): *
Address *
City *
State *
Zip *
Phone Number *
Is it okay if we text you at this number?
Gender:
Email Address: *
Are you a citizen or permanent resident of the U.S.A.? *
Race/Ethnicity (please check any that apply):
Hispanic or Latino
Black or African American
American Indian or Native American
White
Asian
Native Hawaiian or other Pacific Islander
Do you consider yourself any of the following:
ESL (English as a Second Language)
Veteran
Foster Child
Homeless
Dislocated Worker

Educational Information:
Are you a former participant of a TRIO Program? *
If you answered "Yes" to the previous question, which TRIO program(s) were you a participant of?
Student Support Services (SSS)
Upward Bound (UB)
Educational Opportunity Center (EOC)
Upward Bound Math Science (UBMS)
Talent Search (TS)
GEAR Up (GU)
Kirkwood Enrollment Information:
When did/will you first enroll at Kirkwood (Semester/Year): *
What is your major/program of study: *
Which of the following are you currently: *
If you transferred from another college or university, where did you transfer from?
What amount of time do you plan to attend college (credit hours per semester)? *
Have you already earned a college degree? *
Will the majority of your classes be taken on the Cedar Rapids campus? *
Do you plan to transfer to another institution? *

Eligibility Information:
Are you a first generation college student? (First Generation means that neither parent or guardian has a four-year college degree.) *
The term "low-income" means an individual whose family's taxable income for the preceding year did not exceed 150% of the poverty level amount. Please use the chart as a guide. (Income will be verified by TRIO staff.)

Size of Family Unit

Low Income Guidelines

1

$20,385

2

$27,465

3

$34,545

4

$41,625

5

$48,705

6

$55,785

7

$62,865

8

$69,945

Do you consider yourself low-income? *
Do you have a documented disability? (i.e. physical, learning, mental health or other) *
If you answered "Yes" to the previous question, is the disability documentation on file with Kirkwood's Learning Services Department?

Goals and Strengths:
Briefly explain your goals and strengths as a student.
How did you find out about TRIO?

Signature For TRIO Access and Services:

I understand and give permission to TRIO professional staff members to have access to information relevant to my academic status: admission data, registration information, transcripts and grades, financial aid verification, disability documentation and updates from faculty or staff. This information will be used to confirm my eligibility for TRIO and, if a participant, on an ongoing basis to confirm my progress and identify needs. The data will be retained by the TRIO program and may be released to the Department of Education to fulfill grant requirements.

By signing below, I verify that all information provided on this application is true and accurate, and I grant the Kirkwood TRIO Program permission as stated above.

Please sign here: *
Please select a signature verification type.