Application for Project Success | Hagerstown Community College

Personal Information

Name: *

Street: *

City: *

State: *

Zip: *

Student Email: *

Emergency contact: *

Student ID#: *

Date of birth: *

Phone (home):

Phone (cell):

Gender: *

Female

Male

Contact phone: *

Ethnicity:

optional

Marital Status: *

Citizenship Verification

Are you a citizen or permanent resident of the United States?: *

Yes

Select what number you would like to use for verification: *

Enter number here: *

First Generation Verification

Have either of your parents completed a four-year Bachelor’s degree? : *

Mother

Father

Guardian

None

Check all that apply

Documentation of Low Income Eligibility

A dependent or independent student is required to provide one of the following: *

A signed U.S tax return

Verification of family income from another governmental source

A signed statement regarding income from independent student or parent

Please check at least one. (Higher Education act of 1965, as amended by the Education Act of 2008)

Students With Disabilities Information

Do you have a documented physical, emotional, and/or learning disability? : *

Yes

Are you receiving HCC Disability Support Services (DSS)? : *

Yes

Please note that you must provide authentic documentation of your disability to HCC’s Office of Disabilities Support Services or have documentation from HCC’s Disabilities Support Services Office.

Release of Information

This application is a supplement to the required Hagerstown Community College application and in no way replaces the Hagerstown Community College application.

I understand that I am responsible for adhering to all policies and procedures listed in the current Hagerstown Community College Catalog and Student Handbook. I certify that the information in this application is complete and accurate.

I authorize TRiO Student Support Services to gather information concerning my academic progress (standardized test scores, grade point average, earned credits, transcripts) and financial status prior to my participation in TRiO SSS. I understand this information is used to assist in the determination of my eligibility for SSS, and it will be strictly confidential. I grant permission for TRiO SSS to gather information for follow-up whenever appropriate, including transfer and progress at 4-year institutions. I am aware that my eligibility and financial status will be reported to the U.S Department of Education in accordance with the grant funding regulations. I certify that the information provided on the application is true and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information reported.

I am also aware that the personal information that is provided to the TRiO SSS program will be protected under the Family Education Rights and Privacy Act of 1974. No one will have access to the information unless they work with or for the TRiO SSS program, or are specifically authorized by the student in question to see the information.

Release signature: *

I agree with the above statements.