Access Plus Application

Thank you for your interest in Access Plus!

Please complete this application as thoroughly as possible. You cannot save and restart this application. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.

If you have any questions, contact the Coordinator / Counselor you've been working with.

Personal Information

CCRI ID# *

(This number is eight digits long.)

First Name *

Middle Initial

Last Name *

Name you prefer to be called:

Street Address *

City *

State *

Zip Code *

Mobile Number *

Other Phone Number

CCRI Email Address *

Other Email Address

Preferred Contact Method

Birthdate *

Birthplace *

(City & State or Country where you were born)

Citizenship Status *

(If you are a permanent resident you have a green card)

Gender *

Pronouns

Marital Status

Ethnicity

Hispanic / Latinx *

Race (Please answer all questions by choosing yes or no)

American Indian or Alaskan Native *

Asian *

Black or African American *

Native Hawaiian / Pacific Islander *

White *

Education

Previous Education

Name of High School or Location Where you Received your GED *

Please Upload your High School Diploma or GED Certificate

Month/Year of First Semester at CCRI *

Curent/Desired Major *

Primary Campus *

I am enrolled in 6 or more credits *

I have attended college before *

I plan to complete a 2-year degree *

I plan to transfer to 4-yr school *

Eligibility

Did either parent (or legal guardian) complete a four-year degree before you turned 18 years old? *

How many live in your household that you or your parent(s) support? *

(include yourself in this number)

I filed taxes last year or the year before, or have another form of income verification my Coordinator / Counselor discussed with me. *

If yes, upload a copy of your signed tax return from last year or the year before, or another form of income verification:

(For taxes, upload Federal IRS 1040 form pages 1 & 2. Click here for more information about income verification, or contact your Coordinator / Counselor.)

My parent(s) information was required for my FAFSA: *

If yes, did they file a tax return for last year’s income?

If they filed, upload a copy of their signed tax return from last year or the year before, or another form of income verification:

(For taxes, upload Federal IRS 1040 form pages 1 & 2. Click here for more information about income verification, or contact your Coordinator / Counselor.)

Do you have a documented disability (physical, learning, psychological, or other)? *

If so, answer the next three questions:

Have you registered with CCRI’s Disability Services for Students (DSS)?

Have you provided documentation of disability to Disability Services for Students (DSS)?

Do you plan to seek assistance to accommodate a disability?

Needs Assessment

In order to help you develop a plan for success, we need to know what you feel you will need assistance with.

Please let us know which of the following you would like to discuss with your Access Coordinator / Counselor.

Skills Improvement: (check all that apply)

Study skills

Math skills

Writing/English skills

Note-taking tips

Test taking/preparation

Time management/organization

Academic Support: (check all that apply)

Academic advising

Tutoring

Adjustment to college

Personal counseling

Planning for graduation

Other academic support

Career Planning: (check all that apply)

Career exploration/assessments

Choosing a Career

Resume & interviews information and/or referrals

Internships information and/or referrals

Job search information and/or referrals

Other career planning

Financial Support: (check all that apply)

Apply for financial aid (FAFSA)

Grants and loans counseling

Scholarship information

Financial literacy

Transfer Planning: (check all that apply)

Transfer advising

Transfer visits

College admission information

College admission applications

Background

Please check any of the following that apply to you:

I currently work full-time

I currently work part-time

I drive to school

I commute by bus, walk or get dropped off

I have internet access at home

I have been out of school more than 5 years

I am a single parent

I have difficulty balancing work, school, & family

I am repeating a course to achieve a grade

I volunteer or do community service

I have participated in the following TRIO program(s): (check all that apply)

Student Support Services

Educational Opportunity Center (EOC)

Upward Bound

Talent Search (ETS)

I have participated in the following educational program(s): (check all that apply)

College Crusade of Rhode Island

Gear Up

Talent Development

Other Educational Program(s)

Tell us more about you...

Please answer the following questions as well as you can.

This information will help us understand you better so we can
provide the assistance and support you need.

How do you see the Access Program helping you? *

(Please write a few sentences about what we can do for you)

Is there any additional information you wish to share?

Release of Information

I certify that the information on this application, self-assessment, and release is accurate and complete to the best of my knowledge.

I further certify that the information in the documents I uploaded as part of this application is accurate and complete to the best of my knowledge.

I understand that The Department of Education requires social security number reporting as a condition for TRIO participation, and that my social security number will remain private and confidential.

I hereby authorize TRIO Student Support Services to obtain any information from my educational record that may be pertinent to my participation in the program, including information from Financial Aid, Admissions, the Registrar, Disability Services, CCRI faculty and staff, and the National Student Clearing House.

Sign the pad, type in your full name and check "I agree" - then click on "Sign and Submit Signature."

After, click on "Submit the Application" at the bottom of the page.

*

Signature Type: Simple Start Over

Reset Signature Pad

Click here to start signing.

Pencil
Reset

Signature: (Type in your full name)

I agree to the terms included.

Tool Dialog