*Last Name   *First Name 

*Middle Initial 

Mailing Address  

City     Dorm  Select BANKS HUGHES MILLER Room Number 

ST       Zip      Telephone Number  --

*Race/Ethnicity Please select from the following American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Native Hawaiian or Pacific Islander More than one race No response         * Gender  Select Male Female

Date of Birth // 

* hours in the Select DAY EVENING BOTH program.

Select YES NO *I am a citizen, national, eligible non-citizen or permanent resident of the United States.

Select YES NO *My custodial parent(s) or primary legal guardian(s) has a  bachelor's degree. 
                    Specify who: 

Select YES NO *I have a diagnosed learning, physical or mental disability.

Select YES NO *I applied for Federal Financial aid.  (FAFSA, etc.)

Select 1 2 3 4 5 6 7 8 9 10 11 12 12 + *Indicate the number of persons in your household.

                    Approximate yearly family gross income: 

Select YES NO *I have attended college before. When? 

By checking this box, you indicate you have read, and understand and agree to the following terms and conditions. If you have questions regarding specific information, please contact the trio student support services department at (573) 875-7615.

I authorize the release of appropriate and/or personal documents and information to SSS staff members, including grades and financial aid information, necessary to verify my eligibility and monitor my progress in the SSS program, should i be determined eligible. I understand all information obtained will remain confidential.