LCC SSS Application

APPLICATION FOR PROGRAM SERVICES

SECTION I: DEMOGRAPHIC INFORMATION

Please provide data for each item you can. All items marked with an asterisk (*) are required.

Last Name *

First Name *

Middle Name

Maiden or Other Names

LCC Student ID#

Date of Birth *

Local Mailing Address *

Local Mailing Address Apt/Ste #

Local Address City *

Local Address State *

Local Address Zip Code *

Permanent Street Address

Permanent Address Apt/Ste#

Cell Phone Number

Check here if you DO NOT want us to text you.

Alternate Phone

LCC Student Email Address *

Alternate Email Address

Gender *

Have you ever received accommodations for a disability in an educational setting? *

Are you a US Citizen or Permanent Resident? *

Do you consider yourself to be American Indian or Alaskan Native? *

Do you consider yourself to be Asian? *

Do you consider yourself to be Black or African American? *

Do you consider yourself to be Hawaiian or other Native to Pacific Island? *

Do you consider yourself to be Hispanic? *

Do you consider yourself to be White? *

SECTION II: EDUCATIONAL INFORMATION

Please answer the following questions about your educational history and plans.

What is the name of your High School or GED site? *

What is the year of your HS graduation or GED? *

Please tell us the city and state of your HS / GED site.

Have you participated in any of the following college access and success programs? *

What is your educational goal at LCC? *

What major or program of study do you intend to pursue at LCC? *

SECTION III: PARENT INFORMATION

For this section, any adult who had legal responsibility for the applicant while the applicant was a minor is considered a parent.

What is the highest education level of Parent 1? *

What is the highest education level of Parent 2? *

SECTION IV: FINANCIAL INFORMATION

The information you provide here will help determine whether you are considered a dependent student or independent student according to Financial Aid stipulations.

Are you now age 24 or older OR will you turn 24 years old by June 30, 2023? *

Are you enrolled in a Masters program, Doctorate Degree, or graduate Certification program? *

Do you have a child or children that are your legal dependent(s)? *

Are you currently married? *

Are you under the age of 24 and both of your parents are deceased? *

Were you a ward of the state until you were 18 years of age? *

Are you a Veteran of the United States Armed Forces? *

Were you in foster care after the age of 13? *

Were you ever an emancipated minor as determined by a court judge? *

Are you homeless or at risk of homelessness as deterined by the director of a HUD approved homeless shelter, transitional program, or high school liaison? *

Did you answer "Yes" to any of the above boxes? *

Does your household receive SNAP or TANF benefits?

Household size:

SECTION V: RELEASE OF INFORMATION

SSS personnel will review your academic records as submitted to Labette Community College, including, but not limited to, your LCC transcript, your High School transcript, transcripts from other colleges submitted to LCC, and academic test scores used for course placement.

I hereby authorize the release and/or acquisition of appropriate educational and/or personal documents and information as deemed necessary by the Student Support Services Project Director and/or Academic Advisor for official use at Labette Community College. *

Please select a signature verification type.