Submit Your Application

Thank you for your interest in the Hawaii Community College TRIO-Student Support Services program! Due to the nature of the TRIO-SSS program being funded through a grant from the United States Department of Education, we will need you to provide some personal and financial information to determine your eligibility. All of the information you provide will be kept confidential and only be viewed by the TRIO-SSS Staff.

So that we may determine your eligibility and begin to provide you with services, please take a few minutes to complete the application in its entirety. Be sure to include all signature where required and all supporting documentations, as noted.

*Note: You cannot save and restart this application. Therefore, 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 our office at (808) 934-2719 or email us at hawccsss@hawaii.edu

General Information:

Last Name: *

First Name: *

Middle Name *

Date of Birth *

Hawaii CC School ID#

Marital Status (M: Married/S: Single)

Gender (F: Female/M: Male) *

Mailing Address *

Mailing Address 2

Mailing City *

Mailing Zip Code *

Phone Number (input cell# if no home number) *

Cell Phone Number *

Hawaii CC Email Address *

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Academic Information:

Semester and Year Entering/Entered HCC (i.e. Spring 2022) *

I am Entering/Entered Hawaii CC as a: *

Is Hawaii Community College Your Home Campus? *

Do Your Have a 2-Year College Degree? *

Do You Have a 4-Year College Degree? *

I Have Earned the Following College Credits *

What Is Your Academic Standing? *

I Earned a: *

How Many Classes Are You Enrolled/Or Planning to Enroll In? *

Is English Your First Language?

My Program of Study (Major) is: *

I Plan to Earn a:

Do You Plan to Transfer to Another College? *

I Have Taken or Plan to Take: (Select One) *

Eligibility Information:

Citizenship:

Are you a Citizen, National, or Permanent Resident of the United States?

First-Generation College Student:

Mother's Educational Level: *

Father's Educational Level *

Have you ever been in foster care or in a court appointed guardianship? *

Documented Disability:

Do You Have a Documented Disability? *

Are you receiving academic accommodations through (HawCC's Disability Services)? *

If Applicable: Upload Disability Documentation

Race/Ethnicity (answer all & select all that apply):

Race, American Indian or Alaskan Native *

Race, Asian *

Race, Black or African American *

Race, Hawaiian or other Native to Pacific Island *

Race, Hispanic

Race, White *

Veteran Status:

Are you a Veteran of the Unites States? *

Low-Income Verification:

TRIO-SSS is a program federally funded through the United States Department of Education, and for grant compliance, we require supporting documents to verify program eligibility. Information for this section will be strictly in determining your eligibility. Please take a moment to read through and complete this section. We assure you that we will keep this and all information confidential.

An Independent Student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, or someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.

If you do not meet any of the criteria for being an Independent Student, you are considered Dependent Student (parents claim you on their federal taxes)

Please use the following household number and "Taxable Income" guidelines for the state of Hawaii:

For family units with more than 8 members, add $8,145 for each additional member.

If you or your parent(s) filed 2020 U.S. federal income taxes, "Taxable Income" can be found on line 15 of the 1040 form.

Please note that taxable income is usually less than the adjusted gross income.

Example 1: If there are 6 people in your household, see if your household’s “Taxable Income” is at or below $64,170.
Example 2: If there are 9 people in your household, you would check to see if your household’s “Taxable Income” is at or below $88,605.

Household Number	Taxable Income
1	$23,445
2	$31,590
3	$39,735
4	$47,880
5	$56,025
6	$64,170
7	$72,315
8	$80,460

Please select one of the following: *

Financial Aid Information

Did you Apply for FAFSA (Financial Aid) *

Are you receiving Federal Pell Grant? *

Academic Need:

Academic Need (select at least one) *

Which TRIO services are you interested in? (check all that apply)

Student Success Workshops

Academic/Career/Personal/Transfer/Financial Advising

FAFSA Assistance & Information/Financial Literacy

Tutoring & Coaching

Computer Use/Printing

Life/Study Skills Assistance

Campus Resources/ Loan Equipment

Cultural/Educational/Service Learning Events

Early Registration

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Photo Release:

I give Hawaii Community College, TRIO-SSS program the absolute right and permission to use my photograph in its promotional materials and publicity efforts. I understand that the photographs may be used in a publications, print, direct-email/mail pieces, electronic media, (i.e. video, internet, social media platforms), or other forms of promotion. I release Hawaii CC, TRIO-SSS program the photographer their, offices, employees, agents and designees from liability for any violations of any personal or proprietary right I make have in connection with such use.

Authorize Photo Release *

Applicant Signature *

Signature Type: Simple Start Over

Signature: (Type in your full name)

I agree to the terms included.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Authorization & Verification

1. I understand that the TRIO-SSS program is funded through a federal grant from the U.S Department of Education and required to verify my eligibility utilizing the information included in this application and supporting documents.

2. I hereby authorize Hawaii Community College TRIO-SSS staff to obtain academic, financial, and other information pertinent to my participation in the TRIO-SSS program.

3. I understand that my application and its contents will be kept in a file at the TRIO-SSS program office, and will be kept confidential in compliance with the Family Educational Rights and Privacy Act (FERPA).

4. I understand that the TRIO-SSS program is not responsible for any grades I receive. The program is only responsible for the clarification of subject matter and for suggestions on how to improve my changes for success.

5. I understand that completion of this forms does NOT guarantee acceptance into the TRIO-SSS program.

6. I certify that the information contained herein is true and complete to the best of my knowledge.

7. I understand that I should maintain an open mind and positive attitude towards students, peer tutor/coaches and other TRIO-SSS staff members.

8. I understand that I am responsible in adhering to the Hawaii Community College/Institutional Student Conduct Code.

9. I understand that once I am accepted into the TRIO-SSS program, I have a participant obligation to update my files as requested by the program and remain in active status.

10. I understand that if for any reason the Program Director feels that my participation is detrimental to the program or other students that I may be dismissed/released from the program.

Sign and Submit:

Terms of Submission: By submitting this application, I acknowledge that all of the above information inputted in this application is correct and accurate to the best of my understanding.

Applicant Signature *

Signature Type: Simple Start Over

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Signature: (Type in your full name)

I agree to the terms included.

Parent/Guardian Signature (if applicant under age 18)

Signature Type: Simple Start Over

Reset Signature Pad

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Signature: (Type in your full name)

I agree to the terms included.