Project SUCCESS Online Application Form Personal Data First Name * MI Last Name * Student ID * Birthdate * Mailing Address * City * State * Zip * Home Phone * Cell Phone Primary # Home Cell Jeffco Email Address Individual Email Address Gender Male Female U.S. Citizen Yes No Veteran Yes No Foster Child Yes No Currently without a Permanent Residence Yes No Primary Language Spoken Ethnicity: Are you Hispanic/Latino Yes No Race American Indian/Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Please check all that apply Eligibility Did either of your parents/guardians obtain a 4-year Bachelor's degree? Yes No Have you applied for financial aid (completed a FAFSA)? Yes No Do you have any student loans? Yes No Educational Data High school attended Year high school diploma was earned OR year GED/HiSET was earned Do you plan to graduate from Jefferson College with a degree and then transfer to a 4-year college? Yes No Do you plan to transfer to another college without graduating with a degree from Jefferson College? Yes No College Major/Field of Study Anticipated transfer institution Highest level of education you would like to pursue Certificate AAS Degree Associate's Degree Bachelor's Degree Master's Degree Ph.D. Concerns Check all items that are of concern to you Uncertain academic/career goals Transportation problems Work demands that conflict with academic goals Lack of money to meet education, living and personal needs Family issues interfering with academic achievement Succeeding in classes Disability concerns Services Check any services that you are interested in: Academic Advising Academic Support Cultural Events Disability Support Financial Aid Assistance Informational Workshops Leadership Development Personal Support Transfer Assistance Tutoring How Did You Find Out About this Program? COL101 Family Member Friend Project SUCCESS Participant Project SUCCESS Staff Other College Employee Other... How Did You Find Out About this Program? Other... Agreement I understand the SSS Program will use the data provided on this form to assist in assessing any academic and/or career planning needs and all information will be kept confidential according to FERPA laws. I hereby authorize the release of appropriate educational, financial aid, income, personal, disability documentation and other information as deemed necessary by the Director of Student Support Services for official use at Jefferson College. I certify the information in the application is true and accurate to the best of my knowledge. If you agree, type "yes" here Signature Clear signature Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question * 6 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.