2012-2013 STUDENT SUPPORT SERVICES APPLICATION
TRiO/Student Support Services (SSS) is college retention and
graduation program which helps students develop the academic skills
and personal development necessary to successfully pursue and
complete a college degree.
TRiO/SSS students are admitted during their first term at Portland
State University, though we do make exceptions.
To qualify, students must be income eligible, first generation college
students (neither parent has a four-year college degree) and/or
students have a documented disability. In addition, students must also
demonstrate academic need.
We only have limited spaces each term, so please turn in your
completed application as soon as possible.
TRiO/Student Support Services @ Portland State University
Smith Memorial Student Union #458
1825 SW Broadway
Portland, OR 97201
Portland State University is committed to providing reasonable accommodations to
TRiO is funded by the United States Department of Education.
Referred by ______________ Date__________
TRiO / SSS Application Checklist:
Read, sign & date the ‘Release of Information’ form located on the last page
Attach your essay
Attach your verification of income
student’s 2011 income tax if independent
parents’/guardians’ 2011 income tax if dependent
Financial Aid Student Aid Report (SARS) PDF Version
Return completed Application to
Smith Memorial Student Union (SMSU) Room 458
mail to: Portland State University
c/o TRiO/Student Support Services
1825 SW Broadway SMSU 458
Portland, OR 97201
Financial Aid Student Aid Report (SAR) PDF Version
Students qualify for the TRiO/SSS program by meeting at least one of
low-income student (family meets Federal Government
Income Eligibility Guidelines and verified by Portland State
first-generation college student (signifies that parent(s) did
not graduate from 4 year institution)
college student with documented disabilities via the
Disability Resource Center (DRC)
In addition, ALL TRiO/SSS applicants to our program must:
be undergraduate students who are admitted full time at
Portland State University (12 credits or more per term, no quick
be U.S. citizens or permanent residents
Registered and already taking classes (if they are new at
PSU they can apply at the beginning of their first term)
Less than 135 college credits
demonstrate academic need (in general successful applicants
have between a 2.5 - 3.5 college GPA)
When there is limited space in the TRiO/SSS program, priority will be
Students who participate in our Summer Bridge program
Students who are both income-eligible and first generation
Students who are both income-eligible and have disabilities who
require educational accommodation
Alumni of other TRiO programs (Upward Bound, Educational
Talent Search, Educational Opportunity Center, other Student
MOST IMPORTANTLY, students MOTIVATED to make full use of
TRiO/ SSS services to become a successful PSU graduate. It is
expected that participants meet with a SSS advisor at least
once a term. To be competitive for SSS funding, students
may be required to meet twice a term with a SSS advisor.
CONFIDENTIALITY OF INFORMATION
Financial information and all other personal information you give to the TRiO/SSS
program is sent to the U.S. Department of Education and is protected by the Federal
Education Right to Privacy Act. No one may see the information unless they work for
Portland State University, TRiO/SSS, or if you specifically authorize them to see the
information. The information is necessary to determine if you are eligible to
participate in the program and helps us to measure your success. The U.S.
Department of Education has access to this information to help make TRiO/SSS a
first middle last
Email Address ____________________________ @pdx.edu
ODIN (Banweb) Username ____________________________
street apt. #
city / state zip
PSU Student ID Number: _________________
Primary Phone: _________________
Birthdate: ____/____/____ (dd/mm/yy)
Gender: Female Male
Grade level at PSU as of: ___________ (Term and Year)
□ First-year Freshman (0-44 credits) □ Sophomore (45- 89 credits)
□ Junior (90-134 credits) □ Senior (135+ credits)
Please check all that apply:
□ H.S. diploma □G.E.D. □Transfer student from _____________
□ Out of school for more than 5 years □ PSU Summer Bridge Program
Are you a former TRiO Student? (Upward Bound, Talent Search, SSS,
If yes, which program and school?______________________________
Are you a US Citizen? □ Yes □ No Social Security#_ _ _ - _ _ -_ _ _ _
If permanent resident or refugee, please enter alien registration number
Please have your Resident/Refugee/Alien card with you for
Identification at the time of your application review.
Racial/Ethnic Background: Please check (√) all that apply (optional).
□ American Indian/Alaskan Native □ Asian
□ Black/African American □ Hispanic/Latino
□ Native Hawaiian or Pacific Islander □ White (Non-Hispanic)
Student Disability Status
Do you have a disability that requires academic accommodations? □Yes
Are you registered with Disabilities Resource Center (DRC) to receive
If yes, do we have your permission to contact the DRC to receive a
copy of your accommodation letter?
Most TRiO/SSS students must come from a family in which no
parent/guardian with whom the student has lived with has
completed a four year college degree.
Complete only for parent(s) or guardian(s) that you primarily lived with while
attending high school. For other circumstances, please explain with an
attached letter of explanation (no longer than 3 paragraphs.)
With whom did you live with during high school? _____________________
Parent/Guardian’ Father/Stepfather/Guardi Mother/Stepmother/Guardi
s Educational an an
Please () where Please () where applicable
e degree (master’s,
Some college (less
than 4 years)
High school graduate
Some high school
Junior high or
Did you apply for (FAFSA) student financial aid for 2012-2013? □Yes
Did you receive Financial Aid? □Yes □No
Are you receiving any scholarship(s)? □Yes □No
If yes, please list name of scholarship and amount.
1. _________________________ $________
2. _________________________ $________
3. _________________________ $________
THIS IS NOT A SCHOLARSHIP PROGRAM.
Federal regulations require that all participants in TRiO/SSS
demonstrate academic need for program services.
TRiO/SSS offers assistance in the following areas, if accepted what services
are you most likely to use?
□ Academic advising (registration, long-term planning including graduate or
□ Priority registration for following term
□ Financial aid counseling (award letter evaluation and assistance in filling
□ Financial literacy (money management, understanding PSU billing system,
□ Scholarship referral and application assistance
□ Academic counseling (goal-setting, progress monitoring)
□ Study skills development (workshops or individual)
□ Tutoring assistance and referral
□ Writing assistance
□ Personal/social advising (i.e. transition to college issue, transition to work
□ Career counseling (internships, employment, Career Center referrals)
□ Self-advocacy skill building
□ Connect with the larger PSU Campus
□ Other; please state specific areas in which you would like assistance
Please write a short essay (no longer than 1 page) stating why you are
applying to the TRiO/Student Support Services Program. Comment on your
expectations, the benefits you hope to receive, and what commitments you
are willing to make.
This will also serve as a writing sample, so please revise and edit before
turning this in.
Include essay with completed application.
RELEASE OF INFORMATION
All family and student information at TRiO/SSS is kept confidential and
will not be released without permission. TRiO/SSS would like your
permission to access and release family and student information for
the following reasons:
1. TRiO/SSS must report student progress and eligibility information to
the U.S. Department of Education to demonstrate program
effectiveness when requesting renewed funding.
2. At the student’s request to be a reference for employment, scholarship
or internship opportunities.
3. Transfer college admission and financial aid offices will waive
application fees for students from certain economic backgrounds and
will discuss admission and financial aid opportunities with TRiO/SSS
staff only if we have permission to release student information.
4. Portland State University’s Office of Financial Aid will provide us
eligibility information and Financial Aid Award information with your
5. Academic progress monitoring with faculty and instructional support
staff for the purpose of students’ continued academic success and
possible intervention by program staff.
I give TRiO/SSS permission to access and release information on my behalf
for reasons listed above.
Student signature for permission to access and release information
For SSS office use only
Eligibility: ____ low income ____first generation ____disability
Need: HS GPA Low SATV/M Low College GPA PREDICTIVE INDICATORS
____Admit into TRiO/SSS program Assigned SSS advisor ______________
____Not admitted into TRiO/SSS program (circle 1 or more reasons)
- Lack of academic need - Inappropriate for services - Other- _________
__________________________________ Date ____/____/____
Coordinator of Counseling Services Signature
Program Director Signature