Instructions

Thank you for your interest in the REACH|TRIO Student Support Services program at Cazenovia College!  Please complete this application as thoroughly as possible.  Know that you cannot save and restart this application; you may want to skim the page first to make sure you have the necessary answers before starting.  If you have questions, please email our office at reach@cazenovia.edu.

Last Name *
First Name *
Date of Birth *
Gender you were assigned at birth *
Preferred Pronouns
Race/Ethnicity *
Are you an American citizen? If not, specify your status. *
Permanent Address *
Permanent Address 2
City *
State *
Zip Code *
Student Cell Phone *
Email (non-cazenovia.edu) *
High School Graduation Date *
Academic Information:
Major/Program of Study at Cazenovia College *
Is English your primary language? If not, specify. *
Do you have a physical, learning or neurological disorder that has been diagnosed and documented by a medical professional? Or did you have a 504 plan or IEP? *
Were you a member of Upward Bound in high school? If so, where?
Parent/Guardian Information:
Parent/Guardian I First and Last Name
Parent/Guardian I Phone
Parent/Guardian I Email
What is the highest level of education Parent/Guardian I obtained?
Parent/Guardian II Name
Parent/Guardian II Phone
Parent/Guardian II Email
What is the highest level of education Parent/Guardian II obtained?
Taxable Income Information:
Range of Income
0 - $19,320
$19,321- $26,130
$26,131 - $32,940
$32,941 - $39,750
$39,751 - $46,560
$46,561 - $53,370
$53,371 - $60,180
$60,181 - $66,990

My tax status for 2019 was Dependent, Independent, or Other. If other, specify. *
The number of people living in my home is: *
Based on the table above, what range does your TAXABLE INCOME fall? Please copy the range directly from the table, do not give a specific dollar amount. *
General Information:
Are you entering college for the first time? *
Will you be a commuter student? *
Are you planning to be on a sports team at Cazenovia College? If yes, which? *
What areas might you need academic assistance? *
What is your motivation for attending college? *
What obstacles might make it difficult for you to succeed in college? *

Before you submit this application please read the following:

WARNING: Falsifying information on this form is a federal offense, punishable by a fine, or imprisonment, or both. 

By entering my full legal name, I understand this will act as an e-signature. I certify that the information I have provided on this application is, to the best of my knowledge, complete and correct. I understand that by applying for this program, I authorize program staff to obtain records or data pertinent to my participation from other sources, and to release information, as required by law of the terms of the TRIO Student Support Services grant, to the grant funding agency of the United States government. I understand that if I am selected from this TRIO Student Support Services program, active participation in required to maintain membership.

Full Legal Name
Date of Submission