The Modesto Junior College Student Support Services Program (SSS) is a collegiate program funded by the U.S. Department of Education to promote student success, retention, graduation and transfer to a four-year institution, by providing innovative curricular and supportive services. For more information, please visit www.mjc.edu/triosss.

Complete this application as thoroughly as possible.  You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.  If you have any questions, please call (209) 575-6189, email mjctriosss@mjc.edu or visit MJC East Campus Morris Building Room 107. 

 For Non-Tax Filers ONLY: Please download and fill this form before starting your application. This will be a required * field. 

Income Verification Form PDF

NOTE: Once you start application, you cannot save to restart your application.


Student Information:

(Please use all CAPITAL LETTERS when typing your responses)

Last Name: *
First Name: *
Middle Name Initial:
Date of Birth (MM/DD/YYYY): *
Gender: (US Department of Education requires a response in the binary Male/Female, please feel free to add a more specific or different response in the following question.) *
Please feel free to describe/clarify gender:
Marital Status: (S)Single or (M)Married *
MJC W#: (do not include the W) *
Are you a U.S. Citizen? Type YES or NO (if YES, Permanent Resident # does NOT need to be added) *
Permanent Resident #:
Permanent Address (please include apartment/suite if needed): *
City: *
State (CA): *
Zip Code: *
Cell Phone Number: *
Home Phone Number:
MJC Student Email: *
Personal Email Address: *
Please submit a headshot photo we can use for your student file (JPG, PNG) *
How did you hear about TRIO SSS? *

Ethnicity and Race Identity:

According to U.S. federal definitions and for the collection of federal education data.

Hispanic or Latino *

Please indicate one or more Races that apply among the following (as defined by the U.S. Department of Education): 

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, who maintains cultural identification through tribal affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, South East Asia, or the Indian Subcontinent; including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) *Please note this includes Latino/as.

Must respond "YES" to at least one.

American Indian or Alaskan Native *
Asian *
Black/ African American *
Native Hawaiian or Pacific Islander *
White *

Family Background Information:
Has your mother received a Bachelor's degree? *
Has your father received a Bachelor's degree? *
Your parents' primary language? *
Primary language spoken at home? *
Do you have a verifiable learning disability? *
Note: If yes, you may be asked to provide documentation. 
Have you documented your disability with MJC DSPS?
Do you have a documented disability in one of the following areas? *

Tax Information:
Please attach a copy of IRS Form 1040, pages 1 and 2, of your OR parents' 2019 or 2020 Federal Income Tax Return. (NOTE: you are considered INDEPENDENT if you meet one of the following: 24+ years old, married or have a child) For Non-Tax Filers ONLY: Please submit income verification form: *
If you are using parents 1040s taxes please provide parent signature.
Parent Signature: *
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.

For Non-Tax Filers ONLY: Please submit income verification form. Form link can be found at the beginning of this application.


Academic History:
Are you or will you be a High School Graduate? *
High School GPA (0.00): *
If you are NOT a High School graduate, have you passed a GED or High School Proficiency Exam?
Month and year of High School graduation or GED passed exam? (MM/YYYY) *
Have you ever attended other College or University? *
If yes, where?
Total number of college units completed? (if NO college units, enter 0)
Current college cumulative GPA? (leave BLANK if not applicable)
Have you completed a Guidance/Study Skills course? *
If yes, which class?
Do you plan to attend MJC on a full time basis? (12 units or more) *
Note: As a TRIO SSS participant, you are required to enroll in full-time status (12 units or more). 

Educational Objective:
College Major *
Do you plan to transfer to a 4-year university? *
Transfer university 1st choice? *
Transfer university 2nd choice?
Transfer university 3rd choice?
Out of state/Private choice:
Career Goal: *

Other:
Have you completed your FAFSA for the upcoming academic year? *
Have you participated in another TRIO Program such as Educational Talent Search, Upward Bound, and Student Support Services? *
If yes, where and when?

Please indicate YES or NO, if you are receiving services from other programs at MJC?
EOPS *
Disabilities Services (DSPS) *
Veterans? *
Athletics? *
Other:

The following questions will be used to help us provide resources and referrals in the future. 

Do you lack a fixed, regular, and adequate residence? *
Are you a parent? *
Are you a Veteran or a child of a Veteran? *
Are you a foster care youth or aging out of the foster care system? *

Self-Identified Needs:
Please place a "1" in the areas in which you may need assistance:
Personal Counseling
Academic/Transfer Advising
Major/Career Guidance
Stress/Time Management
Math Skills
Study/Note Taking Skills
Communication Skills
Financial Aid
Computer Skills
Access to Technology
Orientation to College Life
Tutoring
Test Anxiety
Other :

Share your personal circumstances, family issues, and/or other concerns which may affect your education at Modesto Junior College? 

*
Do you need to work while attending school? *
If yes, where do you work and how many hours do you work per week?
If you don't work, where would you like to work?
After completing your Bachelor's degree, where do you see yourself employed? *

Share how the Modesto Junior College TRIO SSS Program can help you achieve your academic, career and personal goals? (Please describe as many details as possible)
*

Sign and Submit:

By signing below, I hereby swear or affirm, under penalty of perjury, that all the information on this form is true and complete to the best of my knowledge.  If asked by authorized official, I agree to provide proof of this information, which may include a copy of my and my parent's/spouse/registered domestic partner's income tax return(s).  I also realized that any false statement of failure to give proof when asked may be caused for denial, withdrawal from the program.

Applicant Signature *
Signature Type: Simple    Start Over
Click here to start signing.
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Signature: (Type in your full name)
I agree to the terms included.
Social Security Number *

Privacy Statement:

The information that you provide to TRIO Student Support Services Program is retained in the program office and is protected by the Federal Family Education Right and Privacy Act. Only authorized personnel will see this information. The U.S. Department of Education has the authority to gather the information in order to determine eligibility for the program and to evaluate the success of the program services.