Thank you for your interest in our TRIO Student Support Services program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application.  You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.  If you have any questions, please call Brittany at 330-480-0726 ext 3114 or email

General Information:
First Name *
Middle Name
Last Name *
Date of Birth *
Permanent Address *
City *
State *
Zip Code *
Social Security Number *
Phone Number *
Email Address *
Gender *
By checking this box you certify that you are a U.S. Citizen
Please indicate your race: *
Are Hispanic/Latino? *

Academic Information:
Have you previously completed a degree? *
NOTE: if you have already completed a degree, you will not be eligible for TRIO SSS.
Have you ever participated in any other TRIO program? *
Do you have a High School Diploma or GED? *
How many classes are you currently taking? *
Please list your program of study/major
Did you transfer from another institution? *
Highest level of education desired: *
Do you plan to transfer to a 4 year institution? *
If so, where?

Eligibility Information
Disclosing the following information will allow the TRIO SSS staff to determine your eligibility for our program.
What is the highest level of education completed by your mother when you turned 18? *
What is the highest level of education completed by your father when you turned 18? *
Do you have a disability registered with the Office of Accessibility Services?
How many people are in your household? *
Financial Dependency Status *
By completing entering the following information, you are certifying that the information furnished regarding the family size and taxable income is true to the best of your knowledge.
Full name of parent/guardian completing this form. Independent students will type their name. *
Email of person entering the financial information
Using tax information for 2019, select the correct row. Refer to line 11b on the IRS form 1040 to find your taxable income. Note the size of your family as reported in 2019. Select the row that best describes the family income.
Taxable Income: *
Please upload a copy of your 2019 Tax Return ** this is REQUIRED unless you are a non-filer
  • I authorize Eastern Gateway Community College TRIO Student Support Services (SSS) Program to gather information concerning my academic progress (mid-semester progress reports, standardized test scores, grade point average, earned credits, transcripts) and financial aid information prior to my participation and throughout my involvement in SSS.
  • I understand that this information is used to assist in the determination of my eligibility for the TRIO Programs and it will be held strictly confidential. I am aware that my eligibility, participation and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations.
  • I certify that the information provided on this application is true and complete to the best of my knowledge.
  • I also agree to provide documentation upon request to verify the information reported.
  • I am aware that the personal information that is provided to the TRIO Collegiate Programs will be protected under the Family Education Rights Privacy Act of 1974. No one will have access to the information unless they work with or for the EGCC TRIO Student Support Services Program or they are specifically authorized by me to see the information.
  • Upon formal acceptance into the program, I grant permission for program representatives to have access to my official academic and financial records in order for SSS staff to assist me. Additionally, in the course of my involvement in the SSS program, TRIO staff may consult with various EGCC offices and programs to secure and share the necessary information pertinent to my participation in the program and overall collegiate success.
  • Finally, I give my permission to use photographs, quotes, and statements and/or print my first and last name in any and/or all publications for Student Support Services.
Student Signature *
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Signature: (Type in your full name)
I agree to the terms included.
Parent/Guardian signature if student is dependent
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Signature: (Type in your full name)
I agree to the terms included.
TRIO Student Support Services maintains a Code of Conduct. All participants are expected to behave in a manner consistent with the mission of both the College and the program. Participants are representatives of EGCC and TRIO SSS when they are off campus as well as on campus. The following behaviors are unacceptable: Being disruptive (disrespecting and/or disturbing others, foul or offensive language, or horseplay); Physical and/or verbal abuse or mistreatment of any person; Theft, vandalism, defacement, or damage of property; Use and/or possession of alcohol or illegal drugs; Smoking or use of tobacco in non-smoking areas Participation in the TRIO SSS program is a privilege. Students who violate the Code of Conduct may face disciplinary action including but not limited to having privileges restricted or revoked or facing dismissal from the program entirely. 

By signing below, I agree to the terms of the Code of Conduct agreement and hereby apply for  TRIO Student Support Services at Eastern Gateway Community College.
Student Signature *
Click here to start signing.
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Signature: (Type in your full name)
I agree to the terms included.