Thank you for your interest in joining TRIO Student Support Services.

Please apply only after you  have registered for classes at PNW.

This application will take about 15 minutes to complete.  If you are a dependent student - you will need to have your parent/guardian provide some information (line 15 of their IRS Form 1040 or 1040-SR) and sign. So, you will need to complete this when they are available. If you are an independent student (based on your FAFSA status), you will need to provide your financial income (line 15 of IRS Form 1040 or 1040-SR). So please obtain your tax form prior to starting this application as you cannot modify it later. If you do not file taxes, there is a place to indicate that. 

You must be a U.S. citizen or permanent resident to be admitted into TRIO SSS. If you already have a Bachelor's degree  you are also not eligible. Please do not continue with this application, if you are not a U.S. citizen or permanent resident or already have a Bachelor's degree as we do not want to waste your time. Sorry!

 

GENERAL INFORMATION:
First Name (Legal Name): *
What name would your prefer our staff call you? *
Last Name *
Student PUID: *
Street Address *
City *
Local State *
Zip Code *
Do you live in the PNW dorms? *
Cell Phone Number *
PNW Email Address *
Non-PNW Email Address *
Date of Birth *
Gender *
Please indicate your citizenship status: *
Race, Hispanic *
Race, American Indian or Alaskan Native *
Race, Asian *
Race, Black or African American *
Race, White *
Race, Hawaiian or other Native to Pacific Island *
Are you proficient in a language other than English? If yes, list all languages and proficiency. For example, Spanish - Speaking & Writing *

 

ACADEMIC INFORMATION
What is the highest education level you have completed? *
What is the highest education level your mother/female guardian has completed? *
What is the highest education level your father/male guardian has completed? *
Are you an Indiana 21st Century Scholar? *
Which parent(s) did you regularly reside with? *
Please indicated your current grade level as of today: *
Are you a TRIO Alum? *
Are you taking summer school classes at PNW? *
Do you have a disability? *
Please indicate the month and year that you plan to graduate:

 

TRIO SERVICES DESIRED:
Please check all services you need or would benefit from TRIO SSS to
succeed at PNW:
Tutoring
Financial Aid: Federal (FAFSA, Pell, Loans, Work Study), State (21st Century, Frank O'Bannon), Scholarships
Career Services: Job Searches, Resume/Cover letter Assistance, Networking, Career Advising
Personal Finances: Keeping Student Debt Low, Money Management, Investing
Academic Advising: Degree Planning, Staying on Track, Class Selection
College Success Skills: Study/Memory Techniques, Overcoming Test Anxiety, Time Management, Organization Skills
Graduate School: Information, Visits
Leadership Development, Social/Cultural Activities

PARTICIPANT AGREEMENT:

  • I accept responsibility for my own academic success and agree to attend classes regularly.
  •  I agree to attend at least TWO advising sessions with a TRIO SSS Advisor each semester that I am enrolled, one of which must be a mid-semester review.
  • In addition, I agree to attend additional advising sessions as needed. 
  •  I agree to attend one TRIO  event per semester unless extenuating circumstances have been approved by my TRIO advisor. 
  •  I agree, if my GPA falls below a 2.0, enters academic notice, or does not meet Satisfactory Academic Progress (SAP) to participate in creating an action plan with my SSS Advisor or with PNW's College Success Coach (i.e. academic skills building activities, tutoring, and/or academic advising sessions). 
  • I agree to immediately share details regarding any concerns that may affect my academic focus on school and ask for help when needed.
  •  I agree to keep my appointments with program staff and tutors, or with good reason, cancel as early as possible. 
  •  I agree to check my university email regularly for program information. 
  •  I agree to notify TRIO SSS if I take a semester off, transfer, study abroad or withdraw from the university.
  • If I fail to comply with any part of this contract, I understand I may be dismissed from the program.
  • I understand and agree to the terms of the TRIO Student Support Services Agreement.
I agree to the terms of the Participant Agreement Above: *
Signature Type: Simple    Start Over
Click here to start signing.
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Signature: (Type in your full name)
I agree to the terms included.

 

PROGRAM AUTHORIZATION:

As an actively participating TRIO Student Support Services student or applicant, I:

  • Authorize SSS staff to obtain records of my grades, and if necessary, communicate with professors to obtain that information.
  • Understand that such information will be kept confidential and will be used to evaluate my academic progress and determine appropriate services.
  • Give permission to the SSS staff to divulge to any Purdue University Northwest qualified persons information necessary in order to serve my academic and accommodation needs.
  • Give permission to SSS to contact me by phone, text message, mail, or e-mail involving services I am receiving.
  • Give permission for SSS to use photographs of me on web sites and other Program-related publications.
  • For Students receiving services/accommodations from the PNW Accessibility Center: I give permission to SSS to speak with the Disabilities Services Coordinator on my behalf, and, in so doing, may obtain Information regarding my accommodations and nature of my disability.
Signature - Authorizations *
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.
Please indicate your household size:
To determine your parents’ household size, include those people residing in your home which may include:

1.     yourself;

2.     your child(ren)

2.     your parents;

3.     the number of other children (other than yourself and even if they do not live with your parents) who will receive more than half of their support from your parents between July 1, 2022 and June 30, 2023; and

4.     the number of people who are not your parents’ children but who live with your parents and receive more than half of their support from your parents, and will continue to receive more than half of their support from your parents between July 1, 2023 and June 30, 2024.
Household Size *

FINANCIAL INFORMATION:

This information is necessary as part of our grant requirements.

Please indicate whether you are considered a dependent or independent student (as determined by your FAFSA filing status). Typically, an independent student is 24 or older, has a dependent, is married, or has received approval from the Financial Aid Office to be considered an independent student.
Are you a Dependent or Independent student: *
COMPLETE THIS SECTION IF YOU ARE A DEPENDENT STUDENT. If you are an independent student please choose not applicable for question 1 and enter  NA for question 2. 
1. If you are a dependent student - Did your parent(s)/guardian(s) file taxes in 2023? *
2. If you are a dependent student and your parents filed taxes, Enter amount of their taxable income (line 15 of IRS Form 1040 or 1040-SR) *
COMPLETE THIS SECTION IF YOU ARE AN INDEPENDENT STUDENT. If you are an dependent student please choose not applicable for question 1 and enter NA for question 2. 
1. Did you file taxes in 2023? *
2. If you are an independent student and filed taxes, Enter amount of taxable income (line 15 of IRS Form 1040 or 1040-SR) *

PLEASE UPLOAD A PHOTO:

If you are dependent student, please have your parent/guardian sign this.

If you are an independent student, you will need to sign yourself.
I certify that the financial information provided is accurate to the best of my knowledge. *
Signature Type: Simple    Start Over
Click here to start signing.
  • Pencil
  • Reset
Signature: (Type in your full name)
I agree to the terms included.
If you get a signature error, please check the 3 signature boxes. You may need to hit start over (on the signature part) and be sure to sign in the box next to "I agree to the terms included", check the box and type your name. Then hit the box that says, "Sign and Submit Signature". 
Please tell us if there is anything we should know or that you would like to share regarding your application and/or interest in the program:
Please upload a current photo of yourself (headshot only) *