Submit Your Application

Thank you for your interest in Bloomsburg's TRIO Student Support Services program! Please complete this application as thoroughly as possible. You cannot save and restart this application. You may want to review the questions, take some time to make notes and gather the required information, and then return to submit your application. Required questions are marked with an asterisk (*). Information supplied in this application will be kept strictly confidential and only shared with SSS staff. If you have any questions, please call our office at (570) 389-3606 or email butriosss@commonwealthu.edu.

General Information:

Last Name: *

First Name: *

Middle Name:

Chosen or Affirmed Name:

Gender *

Personal Pronoun(s):

Date of Birth *

Commonwealth University Student ID# (begins with letter "P"): *

Address (Street or P.O. Box): *

Address 2:

City: *

State: *

Zip Code: *

Home Phone

Cell Phone Number:

Please check here if you do NOT wish to receive text messages.

Commonwealth University Email Address (please list alternate email address if unknown): *

Preferred Contact Method

Citizenship Status: *

Race: Do you identify as American Indian or Alaskan Native? *

Race: Do you identify as Asian? *

Race: Do you identify as Black or African American? *

Race: Do you identify as Hawaiian or other Pacific Islander? *

Race: Do you identify as White/Caucasian? *

Ethnicity: Are you Hispanic or Latino? *

Please list any language(s) in which you are fluent: *

Marital Status *

Academic Information:

Year of high school graduation or GED attainment: *

Are you a former TRIO participant (Upward Bound, Educational Talent Search, Educational Opportunity Center, SSS)? *

If you are a former TRIO participant, please list your program and school/institution:

Current Year in School or Academic Credit Standing *

What are your college major(s) and if applicable, minor(s): *

Are you a transfer student? (from another college/university) *

If you are a transfer student, please list your previous colleges or universities attended:

Current or Planned Enrollment Status: *

What year do you expect to graduate? *

Please list your current cumulative GPA (for current college students or high school seniors/recent graduates):

Are you interested in pursuing a degree beyond the bachelor's level? (such as a Master's degree or Graduate certificate)

Eligibility Information:

First-Generation College Determination: *

Do you experience a documented disability? (disabilities can be learning, physical, or psychological) *

If you experience a documented disability, have you ever had an IEP (Individualized Education Plan) and/or a 504 Plan in school?

If you experience a documented disability, are you currently registered with University Disability Services (UDS) to receive accommodations?

Do you authorize UDS to provide accommodations and documentation to support you in the SSS program?

Are you experiencing homelessness? ((i.e., you lack a regular and adequate nighttime residence) or are you at risk of being homeless? *

Have you ever been in foster care or were a dependent or ward of the court? *

Do you have children or other dependents for whom you supply more than half of their financial support? *

Are you a U.S. Military Veteran? *

Financial Information:

Have you completed the FAFSA (Free Application for Federal Student Aid) for the current or upcoming academic year? *

Please indicate your dependency status from the FAFSA: *

How do you plan to pay for your college education?
Check all that apply:

Grants (such as the federal Pell Grant)

Scholarships

Loans

Working

Other

Do you currently work or plan to work while enrolled at the university? If you currently work, please provide information about where you work and how many hours per week you plan to work while enrolled. *

Where do you live or plan to live while attending Bloomsburg? *

Needs Self-Assessment

What academic or other barriers do you feel will be challenges to your academic success? *

Comment on your expectation, the benefits you hope to receive, and/or what interests you most about participating in the TRIO SSS Program: *

How did you hear about the SSS Program? Please list information if you were referred by a friend, professor, or staff member. *

What services are you seeking from TRIO Student Support Services?
Check all that apply:

Academic Services (advising, class scheduling, tutoring, etc.)

Skill-Building (study skills, time management, test taking, stress management, etc.)

Financial Services (financial literacy, budgeting, FAFSA help, scholarship application assistance, etc.)

Career Preparation (major/career exploration, building professional skills, assistance with job/internship applications, etc.)

Graduate or Professional School Preparation (advising, financial counseling, assistance w/ application process, etc.)

Personal Assistance (personal counseling, healthy habits, social connections, campus networking, etc.)

If accepted into the TRIO Student Support Services program, I agree:

1) To be an active participant in the SSS program
2) To meet with the SSS staff/faculty on a regular basis each semester
3) To utilize SSS services (such as tutoring, workshops, etc.) that will benefit my academic progress and help me achieve my personal and career goals
3) To read and respond accordingly to SSS emails/phone calls and maintain regular communication with the program staff/faculty
4) To be invested in my education and motivated to graduate

Information Release:
Submitting this application enables Bloomsburg TRIO Student Support Services to obtain necessary academic and personal information and records, including grade reports & transcripts, admission; enrollment, financial aid eligibility & awards, U.S. residency status, demographic & contact information, for the purpose of determining eligibility, developing education plans, and recording & collecting program statistics. I authorize TRIO Student Support Services program to use information and photographs related to my program participation in newsletters, web pages, media releases, and other program-related publications. This information may be shared with the U.S. Department of Education, Commonwealth University of PA, and TRIO SSS personnel in accordance with federal regulations and university policy.

Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding. Failure to disclose and submit complete and accurate information may result in the denial of acceptance into the TRIO SSS program.

Applicant Signature *

Please select a signature verification type.