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Rogue Community College
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TRiO ROC Participation

(*Required Form Fields)
Personal Information


From last September to today, have you participated in any other TRiO program? *


Ethnicity: Are you Hispanic/Latino? *

Race: *

Identity: *

Are you a U.S. citizen? *

Does your parent/guardian have a 4-year college 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 current income or taxable income from the last IRS tax form you submitted. *

Education Information

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

4. High School (check one): *

Enter name of your high school:

5. College (check one): *

Goals, Personal Statement, and Needs Assessment

6. I am interested in enrolling in college. *

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

8. because: *

9. I would like more information about and/or assistance with: *
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.

* Student Name: *
If you are a Dependent, Parent agreement and Name are required: *
Parent Name: