Project Success Application

Email Address

First Name

Last Name

Student ID

What are your preferred pronouns?

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Mobile Phone

Gender

Race

Emergency Contact Name

Emergency Phone Number

Major

Type of degree

Expected Date of Graduation

Are you planning to transfer to a 4-year college or university?

Yes

No

Transfer school preference first choice

Transfer school preference second choice

Have you taken the IVCC Placement Tests?

Yes

No

Please indicate which tests you've completed:

Reading

English

Math

If you don't apply for financial aid you can not participate in Project Success

Select highest level of education for Father

Select highest level of education for Mother

Will you participate in Project Success sponsored events and workshops?

Yes

No

Do you anticipate a problem with any of your classes this semester?

Yes

No

If you checked other, please list or explain your needs

How did you hear about Project Success (check all that apply)

High School graduate

Yes

No

GED?

Yes

No

Are you a United States Citizen

Yes

No

Are you disabled

Yes

No

Do you release rights to photographs taken by any IVCC employee for use in possible promotional or other material?

Yes

No

Income Verification

Are you a Dependent or an Independent Student?

Dependent

Independent

Did you or your family file a tax return last year?

Yes

No

What is the total number of people (including you) in your household?

What was your taxable (not total) income last year?
Your taxable income can be found on the federal income tax return:
On IRS Form 1040, see line 15

By submitting this form I am giving Project Success staff members access to the following information: standardized test scores, high school transcripts, mid semester and semester grades, financial aid office records, admission office records, counseling office records and records pertaining to a documented disability. I also give permission to my instructors to provide written or verbal evaluations of my academic progress to Project Success staff. I also give my permission for Project Success staff members to communicate, on my behalf, with IVCC professional staff/faculty who are not Project Success staff members. I certify that the information contained in the application is, to the best of my knowledge, true and accurate.

In place of your signature, please type your full legal name:

Parent signature is required if student is dependent or under the age of 24. In place of a parent's signature, parent please type your full legal name.