Summer Advance Registration

Summer Advance

Student Information
Student Support Services is a federally funded TRIO Program under the U.S. Department of Education. The Program is designed for eligible students enrolled at Harcum College who demonstrate academic or financial need. All SSS Summer Advance participants are automatically enrolled into the SSS program during the regular academic year. All program participants must meet certain requirements set by the respective government entity. To determine eligibility, please fill out the following information completely. The information you provide is strictly confidential.
First Name:
Middle Name:
Last Name:
Home Address (street, city, state, zip):
Home Phone #:
Cell Phone #:
Harcum Email:
Local Address (street, city, state, zip):
Local Phone #:
Alternate Phone #:
Alternate Email:
Date of Birth:
Citizenship:
If you chose "other" please specify:
Ethnicity/Race
Marital Status:
Do you have any dependents?
If yes, how many?
Are you in the active military/reservist or a veteran?
If yes, Branch?
Educational Background
Harcum Enrollment Date: 
Major/Program of Study:
How many hours/credits are you planning to take each semester?
What are your residency plans?
High School Attended:
Graduated from High School or Received GED? 
Have you previously attended a 2 year or 4 year college?
If yes, transferred from?
Are you a student in the English as a Second Language (ESL) program?
Have you previously participated in (select all the apply): Use Ctrl or Shift keys to multi-select.
If so, what college/university, program or agency was your program affiliated with?
Has either of your parents/legal guardians, with whom you lived, received a Bachelor's Degree (4-year) in the U.S. before your 18th birthday?
Disabilities Verification
Documentation of disability is required for a student to be considered for participation in the TRIO SSS Program.
Do you have a physical or learning disability which requires special accommodations for you to succeed academically?
If yes, is documentation of your disability filed with the Office of Disability Services?
If not on file, please explain your disability:
Academic Goals/Career Plans
What kind of degree are you currently seeking?
What is your long term educational goal?
Services that may interest and/or benefit me: (Check all that apply) Use Ctrl or Shift keys to multi-select.
If you chose "other" please specify:
Income Verification
If you have not applied for financial aid, or have not been awarded a Pell Grant yet, you may need to provide a copy of last years taxes to verify your income.
What is your financial aid status?
Have you been awarded a Pell Grant?
Did you file an income tax form last year under your own name?
Did your parents/guardians or spouse claim you on their income tax form last year?
Do you have permanent housing?
Are you considered homeless/displaced/ward of State or in foster care?
Do you have a job?
If yes, which of the following best describes your job?
Number of persons dependant on family income:
Indicate last year's gross income:
Student Release
Confidentiality Statement: All information provided is kept confidential and is shared among the SSS Staff and other college officials only on a need to know basis. The following limits to confidentiality apply when child/elder abuse is disclosed, when a threat to self or others is disclosed, or when records are legally subpoenaed.

Statement of Agreement and Consent: I affirm that the information provided by me on this application is, to the best of my knowledge, true and correct. Furthermore, I understand by applying for these programs, I authorize SSS to confer with Harcum faculty and staff to gather necessary information in order to provide me with the services that I have requested and to make reports to the Pennsylvania Department of Education and the U.S. Department of Education for the re-funding of these programs. I understand that the information will be kept confidential and will be used for the following specified purposes: a.) student demographic data and record keeping, b.) program evaluation, c.) needs assessment, d.) state and federal reporting and e.) other administrative purposes.
Applicant Signature
Date 




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