TRIO Application Form

* = required field

PART I: APPLICANT INFORMATION
First Name*
Middle Initial
Last Name*
Nickname
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*
Citizenship*
Race/Ethnicity: (check all that apply)*
Do you have a documented* disability (physical disability, learning disability, etc.)?*
*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?
If you were referred to TRIO, please indicate the individual’s name and title:
PART II. ACADEMIC INFORMATION
Student Status*
Expected Year of College Graduation
Have you participated in another TRIO Program or similar support program?*
If yes, please specify
Year of High School Graduation*
Were you home-schooled?*
Did you earn a GED?*
Did you take college courses while in high school?*
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 of exemptions (line 6d on 1040 form)*
Adjusted Gross Income (line 37 on 1040 form)*
Taxable income (line 43 on 1040 form)*
NOTE: Taxable Income is almost always LOWER than Adjusted Gross Income.
Does your financial aid award include the Federal Pell Grant?*
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
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.*
This application must be signed before submitting.*