Project SUCCESS Online Application Form
  For online submission only. * indicates required items.

Personal Data:
*First Name: MI: Last Name:
*Student ID:  
*Mailing Address:


*Home Phone: Cell Phone: Primary #: Home Cell
*Jeffco Email Address:
*Individual Email Address:
Gender: Male Female U.S. Citizen: No Veteran: No Foster Child: No
Currently without a Permanent Residence: No Primary Language Spoken:
Ethnicity: Are you Hispanic/Latino No  
Race: (please check all that apply)  
Black or African American
Asian White Other

Did either of your parents/guardians obtain a 4-year Bachelor's degree? No
Have you applied for financial aid (completed a FAFSA)? No
Number of family members that your parent/legal guardian can claim as a dependent when filing income taxes (including yourself)

Educational Data
High school attended:
Year high school diploma was earned: OR year GED was earned:
Do you plan to graduate from Jefferson College with a degree and then transfer to a 4-year college? No
Do you plan to transfer to another college without graduating with a degree from Jefferson College? No
College Major/Field of Study:
Anticipated transfer institution:
Highest level of education you would like to pursue:
AAS Degree Associate's Degree Master's Degree Ph.D.

Check all items that are of concern to you:
Uncertain academic/career goals
Transportation problems
Work demands that conflict with academic goals (# of hours worked per week: )
Family issues interfering with academic achievement: ( Single parent Childcare problems Illness Lack of support from family)
Succeeding in classes
Disability concerns: ( Self Family Member)

Check any services that you are interested in:
Personal Counseling
Academic Support Transfer Assistance Financial Aid Assistance
Tutoring Cultural Events Disability Support
Peer Mentoring


How Did You Find Out About this Program?
COL101 Project SUCCESS Staff Project SUCCESS Participant  


I understand the SSS Program will use the data provided on this form to assist in assessing any academic and/or career planning
needs and all information will be kept confidential according to FERPA laws. I hereby authorize the release of appropriate educational, financial aid, income, personal, disability documentation and other information as deemed necessary by the Director of Student Support Services for official professional use at Jefferson College.

I certify the information in the application is true and accurate to the best of my knowledge. If you agree, type "yes" here

Click here to print signature page


Student Support Services - Project SUCCESS is 100% federally funded by the U.S. Department of Education.

For additional information on Project SUCCESS, call Student Support Services at (636) 797-3000, ext. 3281, or stop by the top floor of the Student Center, Room 204.

It is the policy of Jefferson College that no person shall, on the basis of age, ancestry, color, creed, disability, gender, national origin, race, religion, or Veterans status
be subject to discrimination in employment or in admission to any educational program or activity of the college. If accommodations for a disability are needed, please
call Christine Platter at (636) 481-3169 or 797-3000, ext. 3169. Individuals with hearing/speech impairments may call TDD phone number (636) 789-5772 (Hillsboro).