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TRIO Achievers

Student Academic Services (SAS)

TRIO Achievers Program Application

Thank you for your interest in TRIO Achievers sponsored by Student Support Services.

The TRIO Achievers, federally funded by a grant from the U.S. Department of Education, is focused on improving retention and graduation rates of first-generation, income-qualified students as well as serving students with disabilities. At Cal Poly, we assist and serve at least 258 students each year.

Services provided include academic advising, tutoring, career information, help with financial aid concerns, workshops, and help understanding academic policies and procedures. We work closely with the Financial Aid Office, Registrar, Student Academic Services, Multicultural Engineering Program (MEP), Academic Skills Center, Career Services, Disability Resource Center and Mustang Success Center. Students who participate in the program literally come from every academic department and major on campus.

Personal Information

Name *

Cal Poly email address *

Phone *

Is English your primary language? *

Yes

What is your primary language?

Emergency contact *

Relationship *

Phone *

Eligibility

The following information is used to determine eligibility for the TRIO Achievers Program. All information will be maintained in a confidential manner consistent with the Federal Family Education Rights and Privacy Act of 1974.

Are you a U.S. citizen or permanent resident of the United States? *

Yes

Permanent residents - please provide residency number

Are you an AB540 student?

Yes

Are you a deferred action or dream act student?

Yes

Do you identify as a first generation student? *

Yes

**Note: First-generation students are defined as having neither parents that graduated from a four year university.

Please check which of the programs below you belong to. *

EOP

CP Scholars

Neither

Do you identify as a Transfer Student? *

Yes

A Transfer Student is defined as someone who begins their college academic career at one institution, earns some credits through completion of coursework, and then decides to transfer to a different school to finish their education.

Parent/Legal Guardian 1 Education *

Parent/Legal Guardian 2 Education

Income verification

	Yes	No
Were you born before January 1, 1996?	Were you born before January 1, 1996? - Yes	Were you born before January 1, 1996? - No
Are you a veteran of the US Armed forces?	Are you a veteran of the US Armed forces? - Yes	Are you a veteran of the US Armed forces? - No
Are you married?	Are you married? - Yes	Are you married? - No
Are you currently, or were you prior to age 18, a ward of the court or orphan?	Are you currently, or were you prior to age 18, a ward of the court or orphan? - Yes	Are you currently, or were you prior to age 18, a ward of the court or orphan? - No
Do you have legal dependents (other than spouse) who receive more than half of their support from you?	Do you have legal dependents (other than spouse) who receive more than half of their support from you? - Yes	Do you have legal dependents (other than spouse) who receive more than half of their support from you? - No

Student Dependent/Independent Status
*If you check "NO" to ALL of the boxes above, you are legally dependent on your parent's income
*If you check "YES" to one or more of the boxes above, you are independent of your parent's income

Are you legally dependent on your parents' income? (Can your parents claim you on their income tax returns?) *

Yes

Number in household (including yourself) *

If you/your family filed income taxes last year, what was your TAXABLE income? *

**Note: Income should include yourself and your parents, if you are dependent on your parents’ income; or you and your spouse, if you are married. If you or your parents did not complete an income tax form, record the total of untaxed income for the household during the previous year.

Total un-taxed income

Have you applied for financial aid at Cal Poly? *

Yes

Are you a veteran?

Yes

Are you currently receiving services from the Office of Vocational Rehabilitation?

Yes

Are you or have you ever been in foster care?

Yes

Do you have a documented disability? (e.g. physical, visual, hearing, learning, or cognitive)

Yes

Have you registered with Cal Poly Disability Resource Center (DRC)?

Yes

Additional Information

What programs are you currently participating in at Cal Poly?

Hold ctrl* for multiple selections

Academic Need

What are your career/professional goals?

How can TRIO assist you in completing your degree?

Select all the areas you feel will assist you in your success.

Please check all of the services that may interest and/or benefit you:

Hold ctrl* for multiple selections

Other

Personal Statement

In the space provided, write your autobiography. *

Include any information you feel will assist us in learning as much about you, your interest, and your need for the services provided by TRIO Achievers. Your autobiography may include such things as your birthplace, where you grew up, why you want to participate in TRIO Achievers, how TRIO Achievers can assist you, which services can you benefit from, academic achievements, academic struggles and your goals in life.

Information Release Full Legal Name

I understand that as a participant in TRIO Achievers (also known as Student Support Services), any or all of the academic support services of Student Academic Services (SAS) will be available to me. I understand that all data collected will be kept confidential. By typing my full legal name in the box below and clicking submit, I grant permission to TRIO Achievers to track all of my academic progress at Cal Poly and at any other academic institution. I authorize the release of my student academic, personal and financial aid records for the TRIO Achievers program to use and for reporting purposes to the U.S. Department of Education. In addition, I hereby give my permission for my photograph, work and/or statements to be used by TRIO Achievers for promotional, publicity or instructional purposes. All information provided is accurate to the best of my knowledge.

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Less than $19,320	$26,131-$32,940	$39,751-$46,560	$53,371-$60,180	$66,991 and above
$19,321-$26,130	$32,941-$39,750	$46,561-$53,370	$60,181-$66,990

Advisor	Instructor	Website	TRIO Achievers Staff Member	Cal Poly Staff Member
Counselor	Fellow Student

TRIO Achievers

Student Academic Services (SAS)

TRIO Achievers

Student Academic Services

Student Academic Services

TRIO Achievers Program Application

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