Thank you for your interest in our TRIO/Student Support Services program!  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, please email us at

General Information:
School ID
Last Name: *
First Name: *
Middle Name:
Date of Birth: *
Gender: (F) female (M) male
Address: *
Address 2:
City: *
State (PA): *
Zip Code: *
United States Citizen: *
Home Phone
Cell Phone Number:
Westmoreland Email Address: *
Ethnic Group/Race:
American Indian or Alaskan Native *
Asian *
Black or African American *
Hawaiian or other Native to Pacific Island *
Hispanic *
White *

Academic Info:
Mothers Educational Level:
Fathers Educational Level:
Are you a High School Graduate/GED:

Optional Information:
Primary Disability:

Sign and Submit:

Please be sure to use the Signature Pad to sign your application as well as type in your full name below the Signature Pad.

Applicant Signature *
Signature Type: Simple    Start Over
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Signature: (Type in your full name)
I agree to the terms included.
Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding. You are interested in being considered for a program that would provide assistance and support through counseling, tutoring, and other resources to help you achieve your education goals. You authorize the staff of TRIO/SSS to obtain information from your instructors, Admissions, Records, and Financial aid Offices pertinent to your participation in the program.