Thank you for your interest in our TRIO Student Support Services program at Randolph and Williston!  Please complete this application as thoroughly as possible.  You cannot save and restart this application.  If you have any questions, please call us at: 802-728-1396 (Randolph) / 802-879-2329 (Williston).
Student Information
Last Name: *
First Name: *
Middle Initial:
Preferred Name:
Date of Birth (xx/xx/xxxx): *
School Email Address: *
Student ID: *
Cell Phone Number:
May we text you periodically with reminders and timely information to support your success?
Campus: *
Do you already have a 2 or 4 year college degree? *
VTSU Academic Support is funded in part by a TRIO grant from the U.S. Department of Education. This grant enables us to provide additional academic support services to students who are first generation college students, low-income students, or students with documented disabilities. Your answers to the questions below will assist us in determining your eligibility.
Family and Financial Information
With whom do you live (or, if independent, whom did you live with at age18)? *
What is the highest level of education completed by either parent (biological or adoptive)? *
Ethnicity:
Are you a U.S. citizen?
Have you applied for Financial Aid? *
Did you receive a Pell Grant? *
Academic Information
Do you have a documented disability? *
Program of Study:
Institution Start Date: *
Anticipated Graduation Date:
Please describe at least two areas where you are strong academically:
What is the largest academic obstacle you are currently facing? Please check all that apply:
Low High School Grades
I have a GED
Lack of academic preparedness for college level coursework
Lack of academic and/or career goals
Limited English proficiency
Low college grades
Need for academic support to raise grade(s) in required course/academic major
Out of the academic pipeline for more than 5 years
Did you participate in any of these programs?
Students may be eligible for additional services, including the chance to apply for the TRIO Opportunity Grant.  If you would like to be notified about TRIO opportunities, be sure to go back and check the box to allow us to text you!
Sign and Submit

Confidentiality and Student Signature:

Important! Academic Support staff handles student information confidentially to assist in verifying your TRIO eligibility to the Federal Government and/or providing you with academic/personal services. Your signature below verifies your agreement with the three statements below.

1. I authorize Academic Support staff to obtain disability data, obtain financial aid documents, verify citizenship and verify my academic standing (when necessary) to either provide or initiate Student Support Services for me.

2. I give Academic Support staff permission to request feedback from my professors and I agree to meet with the Academic Support staff if my professor(s) indicate that my performance is unsatisfactory.

3. I certify that the information I have provided on this application is correct to the best of my knowledge. I understand that if any of this information is found to be false, my eligibility for Student Support Services will be jeopardized.
Applicant Signature *
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.