Thank you for your interest in Lake Region State College Student Success! Please complete this application as thoroughly as possible. You cannot save and restart this application. If you have any questions, please call our office at 800-443-1313 ext. 21642 or send an email to jayde.vanfleet@lrsc.edu. 
GENERAL INFORMATION:
FIRST NAME: *
MIDDLE NAME:
LAST NAME: *
MAIDEN NAME:
DATE OF BIRTH: *
MAILING ADDRESS: *
MAILING ADDRESS:
CITY: *
STATE: *
ZIP: *
CELL PHONE: *
EMAIL ADDRESS:
STUDENT ID #:
SEX: *
WHAT ARE YOUR PRONOUNS?
SELECT ALL THAT APPLY:
AMERICAN INDIAN/ALASKAN NATIVE: *
ASIAN: *
BLACK/AFRICAN AMERICAN: *
CAUCASIAN/WHITE: *
HISPANIC: *
NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER: *
MARITAL STATUS:
NUMBER OF CHILDREN:
US CITIZEN/RESIDENT ALIEN: *
VETERAN:
ELIGIBILITY INFORMATION:
HAVE YOU APPLIED TO TRIO BEFORE?
DO YOU PLAN TO APPLY FOR FINANCIAL AID? *
DO YOU HAVE A DOCUMENTED DISABILITLY? EXAMPLE: IEP/ISP/RIT OR 504 PLAN *
WOULD YOU LIKE TO SEE IF YOU QUALIFY FOR ACCOMMODATIONS? EXAMPLE: TEST ANXIETY, ADHD, ETC. *
PLEASE SELECT THE HIGHEST LEVEL OF EDUCATION ACHIEVED BY PARENT #1: *
PLEASE SELECT THE HIGHEST LEVEL OF EDUCATION ACHIEVED BY PARENT #2: *
FAMILY SIZE: *
HOUSEHOLD INCOME: *
ACADEMIC INFORMATION:
START TERM:
ACADEMIC MAJOR/PROGRAM:
ARE YOU A NURSING STUDENT?
IF YES, WHERE ARE YOU TAKING CLASSES?
LRSC INFORMATION:
WILL YOU BE LIVING ON CAMPUS?
ARE YOU A STUDENT ATHLETE?
OPT OUT: I DO NOT GIVE STUDENT SUCCESS/TRIO PERMISSION TO CONTACT ME VIA TEXT MESSAGE
TO THE BEST OF MY KNOWLEDGE, I AM PROVIDING INFORMATION THAT IS ACCUARTE AND IN ACCORDANCE WITH THE US DEPARTMENT OF HEALTH AND HUMAN SERVICE.
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I AUTHORIZE THAT ALL INFORMATION PROVIDED ON THIS APPLICATION, INCLUDING MY PERSONAL AND ACADEMIC DATA MAY BE SHARED WITH TRIO STUDENT SUPPORT SERVICES AT LRSC TO SECURE OR RELEASE THE NECESSARY INFORMATION PERTINENT TO MY PARTICIPATION IN THE PROJECT. THIS MAY INCLUDE TRANSCRIPTS, EVIDENCE OF FINANICAL AID, ATTENDANCE RECORDS, AND OTHER DOCUMENTS. I UNDERSTAND MY RESPONSIBILITY TO UTILIZE AND PARTICIPATE IN PROGRAM SERVICES TO MEET INDIVIDUAL GOALS AND OBJECTIVES. 
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SIGN AND SUBMIT:
APPLICANT SIGNATURE: *
Please select a signature verification type.

THE SIGNING PARTY AGREES THAT THIS ARGEEMENT MAY BE ELECTRONICALLY SIGNED. THE PARTY AGREES THAT THE ELECTRONIC SIGNATURES APPEARING ON THIS AGREEMENT ARE THE SAME AS HANDWRITTEN SIGNATURES FOR THE PURPOSES OF VALIDITY, ENFORCEABILITY, AND ADMISSIBILITY.