Student Support Services QUEST Program
Salt Lake Community college
Summer 2011 Application
Name (last) (first) (initial) SSN
Your E-Mail Address
Parent or Guardian Relationship
Gender Ethnic Background
Female Black Caucasian Native American Pacific Islander
Male Asian Hispanic Other:
Date of Birth # Children Age(s)
Trio Participant? Where Who referred you?
Citizenship: U.S. Citizen Permanent Resident #A Other
First Generation: What is the highest level of education completed by your
Low Income: Income Verification Document attached
Language(s) spoken in the home:
(Please answer the following questions to the best of your ability.)
Describe your high school experience
How have your educational experiences and life experiences prepared you for college?
What concerns do you have about attending college?
Please tell us about your educational and career goals and what may keep you from achieving them.
Please describe a positive attribute which you possess that will help you reach out to others in your community.
I authorize Student Support Services (SSS) to gather information concerning my academic progress and financial aid
status. I understand that this information is used to assist in the determination of my eligibility for SSS and it will be
strictly confidential. I grant permission for SSS to gather information for follow-up whenever appropriate including
transfer and progress at 4-year institutions. I am aware that SSS reports to the U.S. Department of Education in
accordance with the grant funding regulations. I certify that the information provided on this application is true and
complete to the best of my knowledge. I agree to provide documentation upon request to verify the information
reported. I am aware that the personal information provided to SSS is protected under the Family Education Rights
and Privacy Act of 1974.
Students Signature Date
Parent or Guardian Signature Date