Trio - Student Support Services Application Form

Student Support Services is a federally funded program of the U.S. Department of Education. Acceptance into the program is contingent upon meeting eligibility criteria and space availability. Please answer all questions completely. If a question does not apply to you, complete the question by marking “N/A”. All information supplied is held in strict confidence and protected under the Family Educational Rights and Privacy Act (FERPA) of 1974. This application cannot be considered if all information is not included.

Trio Application

Personal Information:

Campus Living Address
Campus Living Address
City
State/Province
Zip/Postal
Home Address
Home Address
City
State/Province
Zip/Postal
Country
Gender/Sex
Ethnicity

Program Eligibility:

Select all that apply:
Please check TRiO programs in which you have previously participated:
Are you a returning adult student beginning college at age 25 or later, and/or have a five-year lapse in your academic career?

Education Information:

Do you have a high school diploma?
Do you have a GED?
Are you a Transfer Student?
Class Standing
What Semester?
Semester Enrollment Status:
Which Associate Degree are you seeking?
Do you plan to continue at UT to complete a Bachelor's Degree?
Do you plan to Transfer to another institution?

Release and Confidentiality of Information:

By signing this, I agree to the release of information pertinent to my participation in the Student Support Services program at Utah Tech University or any higher educational institution, e.g. financial data, test scores, or grades, and certify the information given on this application is true to the best of my knowledge.

I understand and agree that my eligibility, academic, and financial status will be reported to the Department of Education in accordance with grant funding regulations.

I understand and agree that any personal information provided to the Student Support Services program is under the Family Educational Rights and Privacy Act (FERPA) of 1974. No one will have access to the information unless they work with or for the Student Support Services program, or are specifically authorized to see the information. The information is necessary to help determine the success of participants in post-secondary education as authorized by the U.S. Department of Education.

Photo/Likeness Release:

By signing this, I authorize Student Support Services to photograph or film me and consent to the use of my likeness in all publications, educational materials, research, advertising, news media, video, and World Wide Web materials.

I further understand and agree that these materials may be kept on file and/or used by Utah Tech University for potential future uses and further agree to release the college from all liability arising from or relating to the taking, use, publication, or dissemination of such material.