Triumph and Surge Application

* = required fields

Semester * Fall 2023

Student Contact Information

First Name *

M.I.

Last Name *

Address *

Apt#

City *

State *

Zip Code *

Phone Number (Preferred for contact) *

Triton Email Address *

Student Demographic Information

Triton Colleague ID *

Date of Birth *

Racial Identity *

What is your parental status? *

Self-identification is important, and we understand that we each have our own understanding of the words used to describe our own experiences. So that we can best honor your identity and experiences, please describe how you identify in the response box below AND select (as many as you want) from the list below.

In your own words, what is your gender identity?

Please share your pronouns

Select the pronouns you use, even if the same as above. She/Her/Hers He/Him/His They/Them/Theirs Ze/Hir/Hirs No Pronoun No Preference Not Listed Decline To Answer

Student Education Information

High School Attended *

Colleges/Universities Attended *

First Generation Status Information

Does your Mother have a Bachelor's (4-year college) degree? *

Does your Father have a Bachelor's (4-year college) degree? *

Are you a PELL Grant recipient? *

Did you Apply for FAFSA/R.I.S.E. act? *

Student Military Information

Serving active duty in the armed forces? *

Additional Information

What is your housing situation today? Check all that apply. * I have a steady place to live I have a place to live today, but I am worried about losing it I do not have a steady place to live Decline To Answer

What are your concerns about your housing situation? Check all that apply. * Condition of housing Lack of permanent housing Ability to pay rent and/or utilities Safe environment Other Decline To Answer

Are you facing any food insecurities? *

Would you like to receive information regarding nutrition resources. (i.e., food banks/pantries, snap benefits) *

Do you have reliable transportation to and from Triton College? If not, explain below. *

If you answered no to reliable transportation, please explain.

Student Response

Please provide short responses to the following questions:

Why do you want to participate in this mentoring program? *

What do you hope to gain from joining TRIUMPH and SURGE? *

Please explain any scheduling issues that may prevent you from attending weekly workshops and meetings with your advisor/mentor. *

What are your hobbies/interests? *

Student Verification

By signing this application, I attest that all the information on this application is true and accurate. I authorize the release and disclosure of official school records to TRIUMPH and SURGE; understanding that the information in these records will be used only to assess need for program services, including referral for financial assistance, but not limited to scholarships, federal financial aid, work study, monitoring educational progress, evaluate the effectiveness of program activities, and fulfill program reporting requirements. I also allow TRIUMPH and SURGE and Triton College to use my image for program promotional purposes.

Verification Confirmation *(represents electronic signature)

Date * (mm/dd/yyyy)

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Triumph and Surge Application