TRiO Student Support Services Application

Lourdes University’s TRiO program is committed to providing students with personal attention to their academic, cultural and social needs.

Student Full First Name*

Student Full Last Name*

Home Phone*

Home Address*

City*

State*

ZIP/Postal*

Do you live on campus?*

Yes
No

Student Cell Phone*

Can we text you?*

Yes
No

Student Email*

Gender

Martial Status*

Single
Married

Veteran*

Yes
No

What is your academic goal at Lourdes? List your prospective major/minor, degrees you are seeking*

Are you currently registered:*

If expected to register, list the semester you are registering

What is your current Lourdes University status?*

What year in college are you?*

Eligibility Criteria (mark all that apply)*

US Citizen or permanent legal resident
First Generation (neither parent has a bachelor’s degree)
Documented Disability (If you have a documented disability, please contact the Office of Accessibility Services at oas@lourdes.edu or 419-824-3523)
Qualifying income level

Qualifying income level chart

Student Income Verification Checklist

Are you receiving financial aid for the current year?*

Yes
No

Check all that apply:

Pell Grant
Loans
Scholarships
Other

Documentation of Low Income Eligibility (need at least one)*

2022 1040 Income Tax Form
Self-signed statement of low-income based on chart
I do not meet low-income eligibility

I certify that my taxable income for 2022 was below the qualifying income levels Qualifying income level chart

Note: This is only to be used for students with no other way of documenting their low income eligibility (e.g., did not file taxes, did not receive state assistance, and did not apply for financial aid)

Student Needs Assessment

This inventory will help in assessing your needs for services which are offered by the TRiO Program. Please check YES or NO in response to each of the following questions.

I would like to learn more about my individual learning style.*

Yes
No

I would like to manage my time more efficiently.*

Yes
No

I would like to become a better test taker.*

Yes
No

I am interested in academic support/tutoring.*

Yes
No

I need to improve my study habits and skills.*

Yes
No

I need to improve my writing skills.*

Yes
No

I need to improve my math skills.*

Yes
No

I need to improve my reading skills.*

Yes
No

I am confused about where to start in choosing a career path.*

Yes
No

I want to learn which careers typically match my skills, interests, and personality traits.*

Yes
No

I am distracted by personal matters to the point that I am having trouble studying/keeping up with assignments.*

Yes
No

I feel uncomfortable communicating with professors/instructors, staff, and other students.*

Yes
No

I would like to improve my technology/computer skills.*

Yes
No

I need assistance with the financial aid process.*

Yes
No

I would like to learn about disability services on campus.*

Yes
No

I would like to receive academic advising to prepare me for entry into my major.*

Yes
No

I need personal support and encouragement.*

Yes
No

I would like to learn more about cultural diversity.*

Yes
No

I would like to attend cultural activities e.g., museums, theater.*

Yes
No

I would like to participate in activities that benefit others.*

Yes
No

I would like to develop more leadership skills.*

Yes
No

Please state how TRiO services can assist you in achieving your academic goals:*

Why are you interested in TRiO?*

How did you hear about TRiO?*

VERIFICATION AND RELEASE INFORMATION

TRiO/Student Support Services is a program designed to help you graduate. The information provided is confidential and will help determine eligibility for the TRiO program. Discrimination is prohibited on the basis of race, gender, color, national origin, religion, age, disability, marital or parental status, or sexual orientation.
I hereby authorize TRiO/Student Support Services to share any information pertinent to my participation in the program. This information includes, but is not limited to, financial aid information, standardized test scores, transcripts, and grade reports. I also verify that the information provided on this form is correct and complete to the best of my knowledge.

Permission to contact professors/advisor:*

Yes
No

Permission to release name for recognition (scholarships, etc.):*

Yes
No

Permission to take my picture and use for recognition and advertising:*

Yes
No

Agreement & Signature

I understand that I am not accepted into the TRiO program or eligible for services until my application file is complete and I have been approved for admission per a letter from the TRiO Director.
I understand that I must meet participant requirements in order to maintain my TRiO membership.
By including my signature below I certify that all of the information within this form is accurate.

Student's Signature*

Date*