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Thank you for your interest in our Student Support Services program! Please complete this application as thoroughly as possible.  You CANNOT save and restart- so please read the application, make notes and gather required documents.  You might want to type your essay questions in Word and then cut and paste them into the sections of the application. 

 If you have any questions, please call our office at (308) 432-6069.
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General Information:
Last Name *
First Name *
Middle Name *
Date of Birth *
School ID *
Gender *
US Citizen-if you answer no, you are not eligible for the program *
Permanent Address *
Permanent City *
Permanent State *
Permanent Zip *
Cell Phone Number *
CSC EagleMail Address *
How did you hear about Project Strive /TRIO *
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Academic Information:
High School attended - including city and state *
College Grade Level (Start) *
Composite ACT or SAT Score (This will help determine eligiblity. If you did not take the ACT or SAT, fill in N/A). *
Academic Major *
Previous College - include city and state *
If you have an associates degree please indicate

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Ethnicity, Race and Family Information

Ethnicity *
Race *
Has your mother completed a bachelor's degree or higher? *
Has your father completed a bachelor's degree or higher? *
How many people are in your household and living at home? *
Family Income Range (This amount can be round on tax forms 1040-line 11b). *
Have you applied for Financial Aid at Chadron State College *
I have a physical, cognitive, or psychological disability? *
If Yes, is your disability on file with the CSC disabilty Service Office? *
Have you even been in foster care or in a court appointed guardianship? *
Do you have a fixed, regular and adequate night time residence? *

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Financial Aid:

Which categories of financial aid do/will you receive? Check all that apply:
Pell *
Loans *
Scholarships
Work Study *
Other Grants *
No Financial Aid *

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Services and Academic Assessment:

Please check all services you wish to receive assistance with:

 
Academic Planning
Career Counseling/Resume *
Career Exploration *
Financial Advising *
Graduate School Exploration *
Mentoring *
Personal Counseling *
Resource Library *
Stress Management *
Study Skills *
Text Ansiety *
Time Management *
Tutoring *
Describe your background and the personal strengths that help you fulfill your academic goals: *
What specific ways do you want TRIO/ Project Strive to help you? *
Statement of Verification and Disclosure:

I hereby give Project Strive/TRIO my permission to:

*Examine my financial aid information in order to determine my eligibility for the Project Strive Program.

*Access my education records and other relevant information in order to access the services to be provided, and to

   *Evaluate my academic progress

   *Permission to use my likeness for promotional, recruitment and educational purposes.

If selected to participate in the Project Strive program, I will actively strive to fulfill my potential as a student committing myself to pursuit of a baccalaureate degree.

      

Student Signature and Date: *
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Signature: (Type in your full name)
I agree to the terms included.

Parent Signature is required if you are 19 years of age and younger.

Parent Signature, Date and Submit:
Parent Signautre, Date
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.