General Information

1. Last Name
First Name
Middle Initial
2. HCC ID#
3. Date of Birth
4. Street Address
Apt. Number
City
State   Zipcode
5. Gender
6. Email
Home Phone
7. Cell Phone
Alt. Email
If no home/cell phone. provide a number where you can be contacted
8. Please select your ethnicity
9. Where were you born?
10. Martial
11. Number of Children
12. Did either of your parents graduate from a 4-year college/university?
13. Do you have a physical and/or learning disability?
If yes, what is your physical and/or learning disability?
14. Please indicate how you learned about this program:
15. Are you a high school graduate?
(a). If yes, from which high school did you graduate (H.S. Name and Address)?
(b). If no, and you recieved a GED certificate (School or Program Name and Address )
16. Please select your appropriate student type:
17. Please select your current student status at HCC:
18. Are you a degree-seeking student?
if yes, please select the degree you are seeking and identify your major:

Major(s):
19. When did you first enter HCC (Month and Year)?
20. Please select the appropriate option for all the following preparatory courses:
Prep Reading I (REA 0018)
Prep Reading II (REA 0019)
Reading Mod 1 (REA 0055)
Reading Mod 2 (REA 0057)
Reading Mod 3 (REA 0058)
Writing (ENC 0022)
Reading/Writing (ENC 0027)
Writing Module (ENC 0055)
Pre Algebra (MAT 0018)
Integrated Arithmetic Algebra (MAT 0022)
Beginning Algebra (MAT 0028)
Developmental Math Stats and Liberal Arts (MAT 0029)
Developmental Math Module (MAT 0055)
21. Please rank in order of importance to you, (with 1 being the highest priority and 6 being the lowest) the types of assistance you will need if accepted into the Program:
Tutoring
Academic Advising
Personal Advising
Transfer & Graduation Planning
Study Skills
Career Advice

Financial Aid Information

22. Have you applied for Financial Aid this academic year?
If Yes, please indicate the date (MM/DD/YYYY)
Have you turned in verification of your income or your families' income to the Financial Aid Office?
If Yes, please indicate the date (MM/DD/YYYY)
Please select the status next to the type of financial aid you will be recieving and enter the corresponding dollar amount:
StatusAid TypeAmount
Pell Grant(FPELL)
Supplemental Educational Opportunity Grant (SEOG)
Federal Work Study (FWS)
FL Student Assistance Grant (FSAG)
Veteran's Administration Grant
Private Scholarship(s)
Social Security Benefits
AFDC
Direct Subsidized Loan (FDLS)
Direct Unsubsidized Loan (FDUL)
HCC Foundation Scholarship
Minority "Incentive" Scholarship
Minority "Need" Scholarship
African American "Need" Scholarship (AAN)
Florida Bright Futures Medallion Scholarship
Mathematics Access Performance (MAPS)
FL 1st Generation Matching Grant
Other
23. Please check the person(s) who will be responsible for satisfying your financial need while you attend college:
MyselfSpouse Parents/GuardiansEmployer Other
24. Are you in any other special educational or training program(s) which help finance your classes?
If yes, what program?
25. Please select the number of people in your household (including yourself):
Number of children in household under 18 years of age?
Please select your family income range:

***Please provide a copy of parent's and/or your IRS Form 1040, as proof of your annual income for the previous year, or

a) AFDC certification      b) Free or reduced lunch verification      c) Food stamp verification

If you are applying under low income criteria, your application for admission to the TRIO Student Support Services Program will not be accepted without this information.

Please bring to your interview a copy of your parent's and/or your Tax Return (IRS Form 1040) for the previous year;or
a. AFDC Certification
b. Free or reduced lunch verification
c. Food stamps verification

Your application for admission to the TRIO Student Services Program will not be accepted without this information.