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TRIO Test

IMPORTANT NOTE:

This format can be filled out online. Type your response for each item. DON'T FORGET: IF YOU WANT A COPY OF THIS FORM, WHEN YOU HAVE FILLED OUT THE FORM, Use the "Print This Page" button (upper right corner of the form) if you wish to keep a copy. THEN, USE THE "SUBMIT TO TRIO" BUTTON and the completed application will be sent to the TRIO office. Your application will be processed within several weeks. If you have any questions, contact Christine DeGregorio via email: cdegrego@berkshirecc.eduor by phone: 413-236-1681.

Last Name

First Name

SS#

Email

Street Address

City

State

Date of Birth
(MM/DD/YY)

High School Diploma
Yes GED

Ethnicity

American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Black/African American
Hispanic/Latino

White
Asian
More than one race

1. Have you completed a college degree?
(Answer all 4 questions)

4 Year Bachelors Degree
2 year Associates Degree
Beyond Bachelors

Yes
Yes
Yes
Yes

                    

No
No
No
No

2. Do you have a disability?
Has documentation been sent to Coordinator
for Students with Disabilities?

Yes

Yes

No
No


3.
Are you married?


Yes


No

4. Do you have children living at home with you?

Yes

No

5. Did either of your parents complete a
four-year college degree?

Mother:
Father:

Yes

Yes
Yes

No

No
No

6. If under 18, are you an orphan,
in foster care or a ward of the court?

Yes

No

7. Prior to reaching 18 years of age,
were you an emancipated minor or did
you have a court-appointed legal guardian?

Yes

No

8. Are you a US Armed Forces veteran?

Yes

No

9. Are you currently serving on active duty
(for other than training purposes) in
the U.S. Armed Forces?

Yes

No

10. Are you homeless (i.e. you lack a fixed,
regular and adequate nighttime residence)
or are you at risk of being homeless?

Yes

No

11. Are you in need of ESOL services?
(English for Speaker of Other Languages)

Yes

No

Financial Information

Have you applied for financial aid?

Have you been offered a Financial Aid Package to
meet your financial need?

Have you applied for and/or received Student Loans?

 

Yes

Yes

Yes

 

No

No

No

Note: Due to Federal Funding, completion of the Federal Financial Aid Application (FAFSA) is required of all TRIO applicants.

Release: I authorize release of information from my financial and/or academic record as requested by the TRIO Program or as needed by Federal, State or Financial Aid organizations for any legitimate purposes. I also authorize the TRIO staff to verify disability documentation with the Coordinator of Services for Students with Disabilities, if appropriate. I understand this information will remain confidential and will be used only to:

1) Establish eligibility for special services
2) Assess my academic progress and need for services
3) Meet program and federal reporting requirements
4) Obtain admissions/transfer information
5) Obtain college/university-tracking information

Student's Agreement*

Date

* By inserting your name in the Student Agreement section above, you are verifying your interest in applying to BCC's TRIO Program.

Statement of Non-Discrimination: Berkshire Community College is an affirmative action/equal opportunity institution and does not discriminate on the basis of race, creed, religion, color, gender, sexual orientation, age, disability, genetic information, maternity leave, and national origin in its educational programs or employment pursuant to Massachusetts General Laws, Chapter 151B and 151C, Title VI, Civil Rights Act of 1964, Title IX, Education Amendments of 1972, Section 504, Rehabitation Act 0f 1973; the Americans with Disabilities Act, and regulations promulgated thereunder, 34 C.F.R. Part 100 (Title VI), Part 106 (Title IX), and Part 104 (Section 504). All inquiries concerning application of the above should be directed to Deborah Cote; Director of Human Resources, Affirmative Action Officer, and Coordinator of Title IX and Section 504; located in the Susan B. Anthony Center Annex, Room A21, at 413-236-1022. The Commonwealth of Massachusetts Community Colleges' Affirmative Action Plan, which is available in the Human Resources Office, contains a full explanation of this specific policy.

The TRIO/Student Support Services Program is funded by the U.S.Department of Education