Westfield State University TRIO Student Support Services Program Application

Please fill out the application below in order to apply to the TRIO Student Support Services Program at Westfield State University.

In order to receive services from TRIO, a student must demonstrate academic need and must be eligible in at least one eligibility category:

-        first-generation college students, where no parent/guardian received a four-year college degree

-        students from low-income households, or independent students with low income

-        students with a documented disability

You can learn more about our program at http://www.westfield.ma.edu/academics/student-support-services-program-trio

Please email trio@westfield.ma.edu if you have any questions or concerns about your application. We will consult with any student about the network of valuable academic resources at Westfield State!

Thank you!

A #
Date	*
Last Name	*
First Name
Middle Initial
WSU email:
Email #2:
Phone number (best way to reach you):
Phone Number #1: cell or home phone?		Cell Home/Landline
Phone Number #2:
Phone Number #2: cell or home phone?		Cell Home/Landline
Your cell service provider
Are you a commuter or do you live on campus?		Commuter Live on campus
Date of birth (MM/DD/YYYY)
Age
Pronouns
About Your Education:
Major(s):
Minor(s):
Semester and Year enrolled at WSU		Fall 2021 Spring 2021 Fall 2020 Spring 2020 Fall 2019 Spring 2019 Fall 2018 Spring 2018 Fall 2017 Spring 2017 Fall 2016 Prior to Fall 2016
Current level		First-year Sophomore Junior Senior
Special Interests or Activities
Did you transfer to Westfield State from another college?		Yes No
Previous college
Degree received
Were you admitted to WSU through the Learning Disabilities program? Yes No Unsure
Are you a student in the Urban Education Program? Yes No Unsure
Are you enrolled through the College of Graduate and Continuing Education (CGCE)? Yes No Unsure
Documented Disability Verification
Do you have a documented physical, medical, psychological or learning disability? Yes No I have a disability but I don't have documentation.
Is your disability documentation on file with Disability Services? Yes No I need more information about this process.
Are you registered to receive accommodations with Disability Services for this academic year? Yes I intend to register, but have not done so yet. No
Do you need information or assistance regarding Disability Services? Yes No
First-Generation College Student
A “first-generation college student” is defined as a student whose parent(s) / legal guardian(s) have not completed a four-year college bachelor’s degree. The definition also applies to a student who regularly resided with and received support from only one parent/guardian, and whose only such parent/guardian did not complete a bachelor’s or 4-year college degree.
Based on the above definition, are you a first-generation college student? Yes Unsure No
If unsure, tell us what you know or don’t know about your parent/guardian education or your questions:
We ask the following questions to ensure that students are connected to helpful resources at WSU:
Do you have reliable housing during the school year and during breaks? Yes No Unsure
Have you ever been in foster care, been a ward of the court, or in kinship guardianship? Yes No Unsure
Do you experience times when you struggle with affording food or other basic needs? Yes No Unsure
Citizenship
Are you a U.S. citizen?		Yes No
If you are not a U.S. citizen, please check one:		A non-citizen with an Arrival-Departure Record (I-94) A U.S. permanent resident and you have an Alien Registration Receipt Card (I-551) In the U.S. On a F1 or F2 student visa, or J1 or J2 exchange visitor visa, or a G series visa A conditional permanent resident (I-551C) Other (please specify):
If you checked Other above, please specify:
How did you learn about the TRIO program? Staff/Faculty referral Other Student referral I received a letter in the mail Orientation session
Name or Department that referred you, if you recall:
Do you have any questions, concerns, or things you are struggling with right now that we can address right away?
Student Acknowledgement: Please read and type your name in lieu of your signature.
I certify that the information provided on this application is, to the best of my knowledge, accurate and true. As a TRIO Student Support Services Program applicant, I give my permission to TRIO to collaborate with other campus offices to confirm, review, obtain, or make copies of all necessary Westfield State University and prior educational documents (i.e., financial aid records, high school and college transcripts, disabilities documentation, assessment results, etc.) to determine eligibility for and/or enhance the effectiveness of the program and services provided to me. I also give permission for TRIO personnel to share information with appropriate educators and college representatives as necessary to support my educational progress and academic success.
Student Name:
Date: