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Rogue Community College
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TRiO ROC Participation

(*Required Form Fields)
Personal Information
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For the period from last September to the current date, have you participated in any other TRiO program?*


Comment:

Ethnicity: Are you Hispanic/Latino?


Race:






Gender:


Are you a U.S. citizen? *


Did your birth or adoptive parent(s) that you resided with prior to age 18 earn a bachelor's degree? *


Are you proficient in English? *


Military Connections: *
Are you a Veteran?
Are you active duty military?
Are you the spouse of an active duty military person?
Are you the child of an active duty military person?

I am:*
If other:

Income Information

1. How many individuals are supported by the household income (household size)? *

2. Enter your household's taxable income (IRS 1040 line 43, IRS1040A line 27, IRS1040EZ line 6) for the previous year. *

3. Household funding sources (check all that apply) *
a) Wages/salary
b) Unemployment
c) TANF
d) SSI or SSDI
e) Social Security
f) Other

Education Information

4. If you have an Associate's Degree or Certificate, are you returning to achieve another certificate or degree? *



5. Is it your intent to go on to earn a bachelor's degree? *



6. What is your current education level? (check only one) *

Enter name of your high school:






Goals, Personal Statement, and Needs Assessment

7. I am interested in enrolling in college. *

8. I desire to enroll in college to pursue a degree/career in:

9. because:

10. I would like more information about and/or assistance with:
a)
b)
c)
d)
e)
f)
If other:

I hereby certify that this information is correct to the best of my knowledge. By checking the box below, I am granting all TRiO ROC and college personnel access to the information contained on this form and in the RCC system for the purposes of program recording, tracking, and reporting as required by the U.S. Department of Education. I allow TRiO ROC personnel to conduct research pertaining to my educational outcomes as they relate to the TRiO ROC program using phone, email or other digital mediums.