Project Success Application

ILLINOIS VALLEY COMMUNITY COLLEGE

PROJECT SUCCESS

Student Support Services - TRIO Program

SOCIAL SECURITY NUMBER:

TODAY’S DATE:

NAME:

__________________
Last

__________________
First

__________________
M.I. Maiden

ADDRESS:

__________________
Street

__________________
City

__________________
State

__________________
Zip

E-MAIL ADDRESS:

PHONE:

________________
Home

________________
Work

BIRTH DATE:

High School graduate? Yes___ No___ GED? Yes___ No___ U.S. Citizen? Yes___ No___

MAJOR____________________________________ Please Circle one: AA AS AAS Certificate

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 check all tests completed? ___English ___Reading ___Mathematics ___Chemistry

Have you applied for financial aid? Yes___ No___  If no, please tell us why you haven’t

____________________________________________________________________________________

____________________________________________________________________________________

The Federal Government REQUIRES Project Success participants to file a FAFSA for Federal Financial Aid. You MAY be eligible for Project Success even if you are not eligible for financial aid.

Do you have a disability? Yes_____ No_____ If yes, please describe ___________________________________________________________________________________

DOCUMENTATION OF YOUR DISABILITY IS REQUIRED.

TO THE BEST OF YOUR KNOWLEDGE, INDICATE THE HIGHEST LEVEL OF EDUCATION COMPLETED BY YOUR PARENT(S) OR LEGAL GUARDIAN(S) WHEN YOU WERE AGE 18:

Financial Information:

Please identify your family size and income level below based upon the following guidelines:

If you are under the age of 24 and claim no dependents you must include your parents income when determining family size. You must also include your parents’ taxable with your own income if you are in this category

If you are under the age of 24, married, and/or claim dependents on your income tax, do not include your parents or their incomes when determining your family size and income level.

If you are age 24 or older, do not include your parents when determining family size and income level.

If you included your parent’s income, please have a parent sign here: _____________________________

Optional Information

How did you hear about Project Success:____faculty/staff ____counselor ____poster/advertisement

____another student ____other______________________

Please indicate your ethnic background:

NATIVE AMERICAN ...............................................

ASIAN/PACIFIC ISLANDS ......................................

BLACK/AFRICAN AMERICAN ..............................

HISPANIC ..................................................................

WHITE .......................................................................

OTHER, PLEASE SPECIFY .....................................

Gender: Male___ Female___ 

Do you anticipate a problem with any of your classes this semester?

Yes___ No___ 

If yes, which one(s): ___________________________________

Expected date of graduation_________________________

Project Success staff members have my permission to access the following information: standardized test scores, mid-semester and semester grades, financial aid records, admission office records, counseling office records, and records pertaining to any documented disability. I also give permission to my instructors to provide written or verbal evaluations of my academic progress to Project Success staff. Project Success staff members are also permitted to communicate, on my behalf, with IVCC professional staff/faculty who are not Project Success staff members, with the understanding that this information will remain confidential. Additionally, I hereby release rights to photographs taken by IVCC for use in possible promotional or educational materials.

To the best of my knowledge, all information provided on this application is true and accurate at this time.

________________________________________________________
Student Signature

________________________________________________________
Date

________________________________________________________
Counselor Signature

________________________________________________________
Date

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

Project Success Mission Statement

The mission of Project Success is to assist, support and empower students in achieving their academic goals and life-long success.  Project Success provides a comprehensive program promoting student retention, graduation and transfer rates while fostering a campus climate that is inclusive and diverse.  Students are assisted in determining their strengths and limitations. Test results, interviews with counselors, and personal interaction through social and academic activities allow students the opportunity to plan a systematic program of educational, social, and personal development.

Introducing TRIO

The TRIO Programs are federally funded grant programs which are designed to identify promising students beginning in grades six through twelve, provide them information on academic and financial aid, and provided tutoring and support services once they reach the college campus. As mandated by Congress, over two-thirds of the students served must come from families with incomes under $24,000 (family of four) where neither parent (or the custodial parent) has graduated from college.

FOR OFFICE USE ONLY

BASIS OF ELIGIBILITY:

FIRST GENERATION + LOW INCOME ..................................

LOW INCOME ONLY ...............................................................

FIRST GENERATION ONLY ....................................................

DOCUMENTED DISABILITY ..................................................

DOCUMENTED DISABILITY AND LOW INCOME

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