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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. 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: *
Student Username (example- smithc1212) *
Personal Email *
Citizenship Status *
Gender *
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Please check this box if you have a documented disability. This is one of three qualifying eligibility criteria to be in the TRIO program. A disability may be physical or emotional such as ADHD, anxiety, PTSD or depression.
If you have a disability, have you applied for accommodations through the Office of Accessibility Services at Clark State?

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:
Intended Major or Certificate *
Please indicate if you want to complete a degree or a certificate at Clark State *
If "Other" was chosen as your major, please share what field you hope to pursue.
Did you participate in any of the following programs? *
Check this box if you earned a GED.
What year did you graduate from high school or compete your GED? *
Have you been out of school for five or more years? *
Family Information:
Parent/Guardian Educational Level: *
How many people in your household at home? *
Family Income Range: *
(Optional) Most Recent IRS 1040/Income Verification Form
Were you at any time in the foster care system, or in kinship care with relatives or other known adults? *
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? *