Student Support Services /  Project Success Application

Please note that this information will be submitted via non-secure e-mail.  Please do not send your Social Security Number or other information that you would not want someone else to know.  Individuals under the age of 13 should not use this form.

Project Success is a federally funded Student Support Services TRIO program that is designed to improve the retention, transfer, and graduation rates of the 150 low-income, first-generation, or disabled college students whom we serve.

Project Success accepts all students who are seeking an associate’s degree; however, preference will be given to students who intend to transfer to a 4-year college or university.

Please use the "Tab" key on your keyboard to move from one field to the next.

Date:
 

Last Name:
 

First Name:
 

Middle Initial:
 

Maiden/Other:
 

Street Address/PO Box:
 

City:

State:
 

Zip:
 

E-mail Address:
 

Birth Date:
 

Telephone Home:
 

Telephone Work:
 

Telephone Cell:
 

Major:
 

Please choose one:
AA
AS
AAS
Certificate

Expected Date of Graduation:
 

Are you planning to transfer to a 4-year college or university?
Yes
No

Transfer School Preferences (if applicable):
1.
2.  

Have you taken the IVCC Placement Tests?
Yes
No

If yes, please indicate which tests you’ve completed:
Reading
Writing
Math
Chemistry

The Federal Government REQUIRES Project Success Participants to file a FAFSA for Federal Financial Aid. Even if you aren’t eligible for Federal Financial Aid, you may be eligible for Project Success. If you don’t apply for financial aid, you cannot participate in Project Success.

Have you applied for financial aid?
Yes
No, I need help with the forms
No, I plan to apply by (insert date)
No, I do not want to apply

To the best of your knowledge, indicate the highest level of education completed by your parent(s) or legal guardian(s) by the time you reached the age of 18.

Income Information
Please indicate family size and your taxable income as reported on your (and your parents) most recent tax return. 

Family Size
1 person
2 people
3 people
4 people
Other

Taxable Income
$0 - $13,470
$13,471 - $18,180
$18,181 - $22,890
$22,891 - $27,600
$27,601 - $32,310
$32,311 - $37,020
$37,021 - $41,730
$41,731 - $46,440
Other $

Participation Information

Will you participate in Project Success sponsored events and workshops?
Yes
No

Do you anticipate a problem with any of your classes this semester?
Yes
No
If yes, which one(s)?
 

Which services do you anticipate using? (Please check all that apply)

Academic Advising
Career Exploration
Cultural Events
Disability Services
Early Registration Workshops
Financial Assistance/Scholarships
Other
Personal Counseling
Single Parent Information
Transfer Information
Tutoring/Study Skills
Wellness Club

Optional Information

How did you hear about Project Success (check all that apply)?
Poster/Advertisement
Faculty/Staff
Counselor
Another Student whose name is
Other  

Please indicate your ethnic background:
American Indian/Alaska Native
Hispanic/Latino
Asian/Pacific Islands
White/Caucasian
Native Hawaiian/Other Pacific Islander
Black/African American
Other, Please Specify  

Gender:
Male
Female

High School graduate?
Yes
No

GED?
Yes
No

Are you a United States Citizen?
Yes
No

Are you disabled?
Yes
No (If yes, you will need to provide documentation)

How can Project Success help you?
 

 Project Success staff members have my permission to access the following information: standardized test scores, high school transcripts, mid-semester and semester grades, financial aid office records, admission office records, counseling office records, and records pertaining to a documented disability. I also give permission to my instructors to provide written or verbal evaluations of my academic progress to Project Success staff. I also give my permission for Project Success staff members to communicate, on my behalf, with IVCC professional staff/faculty who are not Project Success staff members. I certify that the information contained in the application is, to the best of my knowledge, true and accurate. 

 I also hereby release rights to photographs taken by any IVCC employee for use in possible promotional or other materials.

IVCC provides equal opportunity and affirmative action in education and employment for all qualified persons regardless of race, color, gender, sexual orientation, national origin, age, disability, religion, veteran status or any legally protected classification and it complies with Section 504 of the Rehabilitation act of 1973.

Please note that this information will be submitted via non-secure e-mail.  Please do not send your Social Security Number or other information that you would not want someone else to know.  Individuals under the age of 13 should not use this form.