Application

Students, please be sure you read the Application Requirements and information, as well as completing the application itself. Don't forget to complete the assessment linked above.

Student ID #

*Required - Last Name

*Required - First Name

Middle Initial

*Required - E-mail Address

NOTE: The majority of our contact is through e-mail. We expect you to check your JCC g-mail.

Mailing Address

*Required - City

State Abbreviations

Zip code

*Required - Date of Birth

Gender:

Male

Female

Phone Number/Home

Phone Number/Mobile

Phone Number/Work

Ethnic Background

Citizenship Status: Are you a U.S. citizen or permanent resident?

Yes

No

You may choose more than one option by holding down the "Control" key and clicking several answers...

First-Generation Status (parent/guardian's educational level):

Have you applied for Financial Aid at Johnston Community College?

Yes

No

Did you receive a Pell Grant?

Yes

No

*Required - How many are in your household including yourself?

What is your current family income? Please indicate amount per week, month or year.

You may choose more than one option by holding down the "Control" key and clicking several answers...

Do you receive any of the following services?

Do you have a documented disability that requires academic support?

Yes

No

If yes, what is your disability?

Are you registered with Services for Students with Disabilities at Johnston Community College?

Yes

No

In the process of requesting services

Employment section

Are you currently:

Employed

Dislocated Worker

Actively Job Searching

Not searching for employment at this time

If employed, where?

If employed, how many hours per week?

Have you previously earned a college degree?

Yes

No

If yes, Degree earned and Date:

Have you ever attended college?

Yes

No

If yes, where and year attended:

What was your first school enrollment date at Johnston Community College?

What is your current classification?

Freshman (first semester)

Continuing student (Ive attended before but have fewer than 30 credit hours)

Sophomore (more than 30 credit hours completed)

Not sure

I have:

High School Diploma

GED

Adult High School Diploma

If you've attended college, what is your most recent GPA?

Do you plan to transfer to a four-year college or university?

Yes

No

Not sure

If you plan to transfer, where?

At JCC I plan to:

earn a certificate

earn a diploma

earn a two-year college degree

earn a two-year college degree and transfer to a four-year college

Not sure

I plan on graduating from JCC by:

I am uncertain about when I will graduate & need assistance to figure this out.

Yes, I am uncertain.

*Required - What are your academic goals? (Major, degree, Transfer, etc.)

Briefly explain any obstacles to your educational goal(s) that you currently face.

What services provided by TRiO/SSS do you feel that you could benefit from?

*Required - Emergency Contact (REQUIRED): Name, Relationship, Telephone, Address

How did you hear about the TRiO/SSS program?

The above information is true to the best of my knowledge. I authorize the TRiO-SSS office to obtain transcripts, academic, financial, and disability information as needed.

Yes

No

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