Name *

First

Last

Student I.D. Number (8000#####) *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

(e.g. xxx-xxx-xxxx)

Cell Phone *

Email *

Date of Birth

Ethnicity: Do you consider yourself to be Hispanic or Latinx?

Yes
No

Race: Please check all that apply *

Marital Status

Married
Single

Citizenship

U.S. Citizen
Eligible Non-Citizen
Neither

What is your current class standing at Western? *

Select of one of the following

First semester attending Western:

Fall
Spring
Summer

Year:

Do you plan on completing a 4-year (Bachelor's) degree? *

Yes
No

Do you have college credits that you will be transferring in from either another college or high school? *

Another College (transfer credits)
High School (AP or dual credits)
Neither

Have you served as a member of the United States armed forces? *

Yes
No

Are you a spouse or dependent of someone who has served in the US armed forces? *

Yes
No

Have you participated in Upward Bound, Talent Search, or Gear Up? *

Upward Bound
Talent Search
Gear Up
None

Did either of your parents or legal guardians complete a four-year bachelor’s degree before your 18th birthday? *

Yes
No

Do you have a documented disability? (Physical/Learning/Emotional) *

Yes
No

Agree to terms *

I Agree

I certify that the information on this application is accurate and complete to the best of my knowledge. I understand that falsification of this information constitutes fraud. I authorize TRiO Student Support Services to obtain any information from my educational and financial records that may be pertinent to my participation in the program (i.e. transcripts, ACT/SAT scores, grades, etc.). I understand The Department of Education requires social security number reporting as a condition for TRiO participation, and that my SSN will remain private and confidential. I authorize TRiO Student Support Services to include my photograph in my file and use images of me for program and publicity purposes. *

Digital Signature *

Please type your full name as your digital signature

Date *

TRIO Application

Fill out the form below to apply for TRIO assistance.