TRIO Application Form

* = required field

PART I: APPLICANT INFORMATION

First Name*

Middle Initial

Last Name*

Preferred Name

Luther ID*

Date of Birth*

Home Address (Street or P.O. Box)*

Home City, State, Zip*

Home Phone

Cell Phone Number

Email (other than Luther email)

Luther email

Emergency Contact Name*

Relationship of Contact to You*

Emergency Contact Phone Number*

Gender Identity*

	Male
	Female
	Non-Binary

Citizenship*

	U.S. Citizen
	Permanent Resident
	Non U.S. Citizen eligible for federal student aid

Race/Ethnicity: (check all that apply)*

Do you have a documented* disability (physical disability, learning disability, etc.)?*

	Yes
	No

*Documentation could include information from 504 Plan, IEP, medical doctor, psychiatrist, therapist, etc.

If yes, have you been in contact with Luther College Disability Services?

	Yes
	No

If you were referred to TRIO, please indicate the individual’s name and title:

PART II. ACADEMIC INFORMATION

Student Status*

	New
	Transfer
	Returning

Expected Year of College Graduation

	2022
	2023
	2024
	2025

Have you participated in another TRIO Program or similar support program?*

	Yes
	No

If yes, please specify

Year of High School Graduation*

Were you home-schooled?*

	Yes
	No

Did you earn a GED?*

	Yes
	No

Did you take college courses while in high school?*

	Yes
	No

If yes, college credits earned:

PART III. FAMILY INFORMATION

I currently reside with*

If you responded guardian above, please specify relationship to you

Mother's educational background: (check only the highest level completed)*

Father's educational background: (check only the highest level completed)*

PART IV: INCOME INFORMATION - Required to Determine Financial Eligibility - DO NOT LEAVE BLANK!

The information in this section, required of all applicants, is used to determine eligibility for participation in the TRIO Achievement Program and will be treated confidentially. Last year’s Income Tax Return must be submitted to the Luther College Financial Aid Office.

If you have any questions about this section, please contact the TRIO office!

Indicate "Independent" in the box ONLY IF you are considered to be an independent student for financial aid purposes (then enter "0" in the remainder of the financial section).

Year printed on tax return (enter N/A ONLY IF your family did not file and enter "0" in the remainder of the financial section).*

Family Size (Number in your household, including yourself)*

Adjusted Gross Income*

Taxable income*

NOTE: Taxable Income is almost always LOWER than Adjusted Gross Income.

Does your financial aid award include the Federal Pell Grant?*

	Yes
	No

PART V: NEEDS LIST

The TRIO Achievement Program wants to best serve your needs. Please take a moment to indicate those areas you may need help with as you make the transition from high school to college. Check all that apply.

Academic skills*

Other areas*

Your proposed major

Career interests

I plan to be involved in

	athletics
	music
	other extra-curricular and/or co-curricular activities

PART VI. SERVICES AND ACTIVITIES

Although we would like to offer services to everyone who is eligible, the TRIO Achievement Program is only funded to serve 160 Luther students. Naturally, we want to provide services to students who will take advantage of them and participate for all four years. Please indicate the services and activities in which you wish to participate. Check all that apply.

Please indicate the services and activities in which you wish to participate. Check all that apply*

Can you think of anything that could keep you from completing your degree, such as family, grades, social life, money, motivation, career decision, etc.? Please describe:

PART VII. AUTHORIZATION AND AFFIRMATION

Please read and check each box to indicate you understand these authorizations.*

	I hereby authorize the Luther College TRIO Achievement Program to obtain academic, financial, and other information pertinent to my admission to and participation in the TRIO Achievement Program.
	I understand that a copy of my application form will be kept on file at the TRIO Achievement Program office and that the resulting information received from admission and financial aid officers will be kept confidential in compliance with the Family Rights and Privacy Act.
	I affirm to the best of my knowledge that the information I have provided is true.
	I give permission for TRIO to use photos, etc. of me upon acceptance into the TRIO Achievement Program.

This application must be signed before submitting.*

Tarbabypre

(Please don't fill in this field.)

Tarbaby

(Please don't fill in this field.)

Noturl

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Antlion

(Please don't fill in this field.)

	American Indian or Alaska Native
	Black or African-American
	Native Hawaiian or Pacific Islander
	Asian
	Hispanic or Latino
	White

	Upward Bound
	Talent Search
	Student Support Services
	Gear Up
	Other

	Unknown
	Did not complete high school
	High School
	Some college, no degree
	Associate' Degree
	Bachelor's Degree
	Higher than Bachelor's

	Unknown
	Did not complete high school
	High School
	Some college, no degree
	Associate's Degree
	Bachelor's Degree
	Higher than Bachelor's

	Mathematics
	Writing
	Reading (speed and/or comprehension)
	Science
	Non-native languages
	Music
	General study skills

An Iowa College in the Liberal Arts Tradition

TRIO Achievement Program

TRIO Application Form

Priority deadline is June 30

Connect with TRIO Achievement Program

	Organizational skills
	Social skills and connections
	Time management
	Financial challenges
	Major/career decision-making
	Learning obstacles or disabilities
	Physical or mental health challenges
	Family obligations or expectations
	Other factors impacting college

	FOUNDATIONS FOR LEARNING AND DEVELOPMENT (GS 100): Foundations for Learning and Development, a course available to first-year TRIO participants, sets the stage for the Luther experience and helps you start off strong.
	Free tutoring to ensure you are understanding the material and getting the most out of your education.
	Help with career exploration and finding your purpose!
	Workshops that help you transition and thrive.
	Advice and assistance in course selection.
	Checking out helpful educational tools (i.e. laptop, Smart Pen, etc.) through the technology lending program
	Help in setting and reaching academic, financial, career, and personal goals.
	Help in strengthening your study strategies, organization, or time management skills.
	Understanding and accessing financial assistance to help you pay for college.
	Help in cultivating wise money management practices that will serve you now and throughout your life.
	Assistance with graduate school or professional school exploration and admission.
	Checking out textbooks through the TRIO textbook lending library.
	Peer mentoring from other TRIO particiants.
	Networking/social activities.
	Free supplies and copies.
	Access to TRIO resource library for additional guidance (everything from finances to strengths to vocation).
	Other (please indicate in your answer in the next question, below)