Fillable Student Support Services Danville Campus Program Application Room (Bluegrass Community and Technical College)

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Student Support Services Danville Campus Program Application Room (Bluegrass Community and Technical College)

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Country of origin: US
File type: PDF

U.S.A. forms for Bluegrass Community and Technical College

BROWSE BLUEGRASS COMMUNITY AND TECHNICAL COLLEGE FORMS

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PeopleSoft ID#: ________________
Student Support Services
Danville Campus
Program Application
Student Support Services is a federal program funded through the U.S. Department of Education and sponsored by
BCTC, an equal opportunity institution. Acceptance into the program is contingent upon meeting eligibility criteria
and space availability. Information gathered on this application will be used to determine eligibility and will be held in strict confidence.
Room 104B
PERSONAL INFORMATION
Name:
First Middle Last
Current Address:
P.O. Box or Street Apt # City State Zip
Email:________________________________@kctcs.edu Preferred Phone: _______________ □ Cell □ Home
Social Security Number: _________________________ Date of Birth: _______/_______/________
Ethnicity: □ Hispanic or Latino □Yes □No (please select one additional box below)
Race: □ American Indian or Alaska Native □ Asian □ Native Hawaiian/Pacific Islander
□ White □ Black or African American □ More than one race
Gender: □ Male □ Female
Are you a US Citizen: □Yes □No (If no, please attach documentation to prove status).
ELIGIBILITY INFORMATION
Did either parent of which you resided with as a minor graduate with a bachelor degree? □Yes □No
Do you have a documented disability? □Yes □No
(If yes, have you registered with the BCTC Office of Disability Support Services by submitting documentation of
your disability?) □Yes □No
You may be required to submit written documentation by a qualified professional, physician, or state agency to verify your eligibility with Disability
Support Services.
EDUCATIONAL INFORMATION
High School Graduation Date: _______________________ or GED Completion Date: ___________________
Current education status: ____ 1
st
year (0-29 credits) ____ 2
nd
year (30+ credits)
____ Transfer student ____ Re-entering student (out of college 5 years or more)
Major: _____________________________________________________
Academic Goals:
Do you intend to complete an AA/AAS/Certificate or Diploma from BCTC? □Yes □No
___Certificate ____ Diploma ___ Associate ___ Undecided
Do you intend to transfer to a 4-year college/university? List school ___________________________________
Have you previously participated in other
TRiO programs such as Talent Search or
Upward Bound? □Yes □No
PeopleSoft ID#: ________________
Room 107
** YOUR APPLICATION WILL NOT BE PROCESSED UNTIL TAX FORMS ARE RECEIVED **
FAMILY INFORMATION
Marital Status: □ Single □ Married
Do you have children or other dependents (other than a spouse) who receive more than half of their support from you?
□Yes □No
At any time since reaching 13 years of age, were you an orphan, in foster care, or a ward of the court? □Yes □No
Prior to reaching 18 years of age, were you an emancipated minor or did you have a court-appointed legal guardian?
□Yes □No
Are you serving on active duty (for other than training purposes) in the US Armed Forces? □Yes □No
Are you homeless (you lacked a fixed, regular, adequate night-time residence) or are you at risk of becoming homeless?
□Yes □No
FAMILY INCOME INFORMATION
The federal government requires that SSS/TRiO have on file documentation of the family’s annual TAXABLE INCOME as reported on
the federal tax form 1040, 1040A, or 1040EZ for the prior year.
Have you applied for financial aid at BCTC? □Yes □No
Total number of persons in the household (including yourself): ______
What was your family’s taxable (not total) income? $
My family did not file a federal income tax return for the previous calendar year. □Yes □No
Note: Taxable income can be found on the federal income tax return. On the IRS form 1040, see line 43. On IRS form
1040A), see line 27, and form 1040EZ, see line 6.
STUDENT RELEASE
By signing below, I hereby verify that all the information provided on this application is accurate to the best of
my knowledge. I hereby give permission for the BCTC Student Support Services program to review any
available academic and financial aid records deemed necessary. I understand that this information is
confidential and withholding information on this application or giving false information will make my
application ineligible for admission to the BCTC SSS program.
Student Signature: ____________________________________________ Date: __________________
For office use only:
Date received: _________________
Eligibility: □LI only □ FG only □DI only □LI&FG □LI & DI
Status: □Accepted □Wait List □Ineligible
_______________________ ____________________________ __________________
Director Assigned Advisor Date
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Student Support Services Danville Campus Program Application Room (Bluegrass Community and Technical College)

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Completed 16 September 2020

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