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TRIO Student Support Services: Application Form
TRIO Student Support Services (SSS) makes the college transition smoother by offering one-on-one academic and career advising as well as workshops on managing your time efficiently, getting along with instructors, financing your education, planning your four-year degree and beyond, and many other topics. All services are free to eligible students.
Legal Name
*
First
MI
Last
Preferred Name (if any)
First
Last
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
BHC ID Number
*
Begins with 900-
Campus:
Please select
Quad Cities Campus
East Campus
Phone Number (Cell)
*
###
-
###
-
####
Personal Email
*
Date of Birth
*
MM
/
DD
/
YYYY
Gender
Female
Male
Other
Preferred Pronouns
He/Him
She/Her
They/Them
Marital Status
*
Single
Married
Divorced
Separated
Ethnicity/Race
Are you Hispanic?
Yes
No
Select one or more races from the following that applies to you:
*
American Indian Alaskan Native
Asian
Black or African-American
White
Native Hawaiian or other Pacific Islander
Eligibility Criteria
Are you a U.S. Citizen or permanent resident?
*
Yes
No
Alien Registration Number (if applicable)
Has either parent completed a four-year degree?
*
Yes
No
Do you have a documented disability?
*
Yes
No
Are you receiving Financial Aid? (FAFSA/PELL)
*
Yes
No
Do you plan to transfer to a 4-year university?
*
Yes
No
Date of High School/GED Graduation
*
MM
/
DD
/
YYYY
Name of High School
*
High School GPA
*
Which semester will you start BHC?
*
How did you find out about TRiO?
*
Another student
BHC Staff
Faculty
Orientation
Program Brochure
Website
Other
NEEDS ASSESSMENT
Rate Your Comfort Level in the Following Areas:
COMPUTERS
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very Uncomfortable
Internet & Email
Basic Keyboarding
Formatting Papers and Spreadsheets
Regular Access to Computers
READING
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very Uncomfortable
Remembering What you Read
Staying Focused While Reading
Vocabulary Skills
ENGLISH
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very Uncomfortable
Writing Papers
Citing Sources in Papers
Proper Grammar
Proper Sentence Structure
STUDY SKILLS
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very UnComfortable
Knowing my Strongest Learning Style
Using my Strongest Learning Style
Note Taking
Studying
CAREERS
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very Uncomfortable
Resume Writing
Interviewing Skills
Career Path
FINANCIAL AID / SCHOLARSHIPS:
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very Uncomfortable
FAFSA Application & Process
Knowledge of Grants / Scholarships
Understanding Credit
Creating a Household Budget
MATH
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very Uncomfortable
Completing Math Homework on Own
Studying for Math Tests and Quizzes
OTHER
Very Comfortable
Somewhat Comfortable
Not Sure
Somewhat Uncomfortable
Very Uncomfortable
Stress Management
Time Management
Taking Tests
Overall Health & Welness
Communication Skills
Professionalism
Are you currently working?
*
Yes, full-time.
Yes, part-time.
No, but I would like help looking for a job.
No, I am choosing to focus on school currently.
I would like more information about (check all that apply)...
*
Assistance with child care.
Counseling services.
Assistance with clothing.
Assistance with housing.
Food pantry information.
None of the above.
Please list any barriers that you feel could intefere with your college success:
RELEASE OF INFORMATION
I authorize Student Support Services (SSS) to gather information concerning my academic progress and financial aid status prior to my participation in SSS. I understand that this information is used to assist in the determination of my eligibility for SSS. I grant permission for SSS to gather academic information for follow-up whenever appropriate, including transfer and progress at 4-year institutions. I am aware that my eligibility and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations.
Signature
*
Clear
Use your mouse or touch-pad to sign.
Today's Date
*
MM
/
DD
/
YYYY
I consent to the discussion of my 2024-25 FAFSA data (excluding federal tax information) between Financial Aid and the TRIO Director for the explicit purpose of verifying my eligibility for TRIO program participation and services.
Agree
