Thank you for your interest in the TRIO Student Support Services Program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application at any time.  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 or text  937.328.6122, or email carydevinec@clarkstate.edu.

Referred by *
Today's Date *
General Information:
School ID *
Last Name: *
Middle Name:
First Name *
Preferred First Name *
Pronoun Preferences *
Address: *
Address 2:
City: *
State: *
Zip Code: *
Date of Birth: *
Describe your primary reason for applying: *
Home Phone
Cell Phone Number: *
Campus Email Address: @students.clarkstate.edu *
Personal Email
Citizenship Status - Please check one: *
Gender *
Please check this box if you have a documented disability. This is one of three qualifying eligibility criteria to be in the TRIO program.

Ethnicity: Check all that apply

Race, American Indian or Alaskan Native *
Race, Hispanic *
Race, Asian *
Race, White *
Race, Hawaiian or other Native to Pacific Island *
Race, Black or African American *
Academic Info:
Please indicate the degree or certificate you plan to complete at Clark State. *
Do you want to transfer to a four-year college for a bachelors degree?
Have you been out of school for five or more years since completing high school? *
Check this box if you earned a GED.
What year did you graduate from high school or compete your GED? *
Did you participate in any of the following programs? *

Family Information:
Parent/Guardian Educational Level: *
How many people in your household at home? *
Family Income Range: *
Most Recent IRS 1040/Income Verification Form

Sign and Submit:
Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.
Applicant Signature *
Please select a signature verification type.
What is the best way to contact you? *