Student Support Services/ Project Success Application

If you see this don't fill out this input box.

Student ID*

Date*

Last Name, First Name, Middle initial*

What is your preferred name/pronoun?

Street Address*

City, State, Zip Code*

E-Mail Address*

Birth Date*

Home Telephone Number*

Work telephone number

Cell phone Number*

Phone Carrier (ex: ATT, Verizon, etc)

Emergency Contact Name*

Emergency Phone Number*

Major*

Type of degree*
Please Choose one:

Expected Date of Graduation

Are you planning to transfer to a 4-year college or university?

Transfer school preference first choice

Transfer school preference second choice

Have you taken the IVCC Placement Tests

If yes, please indicate which tests you've completed:

Have you applied for financial aid?
If you don't apply for financial aid you can not participate in Project Success

Check highest level of education for Father

Highest level of education for Mother

Will you participate in Project Success sponsored events and workshops?

Do you anticipate a problem with any of your classes this semester?

Which services do you anticipate using? Check all that apply

If you checked other, please list or explain your needs

How did you hear about Project Success (check all that apply)

Please indicate your ethnic background

For ethnicity, if you indicated other, please specify

Gender

High School graduate

GED?

Are you a United States Citizen

Are you disabled

Do you release rights to photographs taken by any IVCC employee for use in possible promotional or other material?

Please note that this information will be submitted via non-secure e-mail. Please do not send your social security number or other information that you do not want someone else to know. Individuals under the age of 13 should not use this form.

Project Success is a federally funded Student Support Services TRIO program that is designed to improve the retention, transfer, and graduation rates of the 160 low income, first generation, or disabled college students whom we serve.

Project Success accepts all students who are seeking an associate's degree; however, preference will be given to students who intend to transfer to a 4 year college or university.

The Tab key may be used to move from one field to the next.

By submitting this form I am giving Project Success staff members access to the following information: standardized test scores, high school transcripts, mid semester and semeter grades, financiall aid office records, admission office records, counseling office records and records pertaining to a documented disability. I also give permission to my instructors to provide written or verbal evaluations of my academic progress to Project Success staff. I also give my permission for Project Success staff members to communicate, on my behalf, with IVCC professional staff/faculty who are not Project Success staff members. I certify that the information contained in the application is, to the best of my knowledge, true and accurate.