Submit Your Application

Thank you for your interest in our TRIO program. TRIO Student Support Services is a federal grant funded through the U.S. Dept of Education. It is one of eight programs designed to help academically at-risk students stay in school, graduate, and transfer to the next level of learning. There are many reasons to become involved in the programs: college success, tutoring assistance, support from a mentor, an opportunity to participate in cultural activities, access to scholarships and other financial assistance, specially designed workshops, opportunities to meet other students and more. 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 (618) 985-2828 ext 8289.

General Information:

Date *

Last Name: *

First Name: *

Middle Name:

Date of Birth: *

School ID *

Address: *

Address 2:

City: *

State: *

Zip Code: *

Home Phone

Cell Phone Number: *

Email Address: *

Gender *

Marital Status *

Race, American Indian or Alaskan Native *

Race, Asian *

Race, Black or African American *

Race, White *

Race, Hawaiian or other Native to Pacific Island *

Race, Hispanic *

Are you a veteran? *

Are you a U.S. citizen? *

Do you have a disability? *

How do you plan to be successful in college? *

What obstacles do you anticipate may keep you from achieving your goal? *

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Family Information:

How many people in your household at home? *

Family Adjusted Gross Income Range: *

Parents Educational Level: *

How many hours worked per week? *

Were you ever in foster care? *

Are you or have you ever been homeless? *

Are you eligible to recieve Financial Aid? *

Academic Info:

Did you graduate from high school? *

How many classes are you taking? *

How's your academic standing? *

Are you planning to get a degree at JALC *

What is your major? *

Are you planning to transfer to a 4-year institution? *

Referral Information

How did hear about the TRIO program and its services? *

Were you reffer to the TRIO program by a JALC employee? *

Which staff / Instuctor referred you? *

______________________________________________________

Sign and Submit:

Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.

Applicant Signature *

Please select a signature verification type.