Applicant Information

Thank you for your interest in our 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 call our office at 541-440-4712

First Name *
Middle Name
Last Name *
School ID *
Date of Birth
Mailing Address *
City *
State *
Zip Code *
Cell Phone Number
Email Address *
Current Program of Study at Umpqua Community College *
Do you plan to transfer to a 4-year institution? *
Intended field of study/major at 4-year institution *
Do you have a documented physical or learning disability?
Career Goal *
Are you currently enrolled in at least 12 credit hours at UCC?
Has your parent or guardian earned a Bachelor's Degree from a 4-year institution?
If yes, did you regularly reside and receive support from them?
Ethnicity (optional): Do you identify as Hispanic or Latino?
Race:  Check all that apply
American Indian/Alaskan Native
Asian
Black/African-American
Pacific Islander
White
Unknown/No Response
Other
Are you a U.S. Citizen?
If No, enter your Permanent Resident Alien # (if applicable):

Support Services (please check all that apply)

At the Transfer Opportunity Program, we firmly believe in providing the best services possible to ensure student academic needs are being addressed.  Our program participants are provided with a variety of services.  Please indicate the service(s) below that you feel would be most beneficial to your academic success.

Specialized Advising
Career Counseling
Financial Aid Assistance
Campus Visits
Cultural Events (plays, museum tours, etc)
Academic Tutoring
Transfer Assistance
Mentoring
Textbook/Supply Lending
Is there another way not listed that we can support you?
Have you ever Participated in a TRIO program?
Have you ever particpated in a UCC program?
How did you hear about the Transfer Opportunity Program?

Income Verification Step 1

The following questions will help the Transfer Opportunity Program determine if you meet federal low income guidelines. 

Are you married or separated but not divorced?
Do you have any dependants who receive more than half of their support from you?
At any point since you turned 13, were you in foster care?
Are you a US Armed Forces Veteran or currently serving on active duty?
Do you have independent status with financial aid?

Income Verification Step 2

If you are less than 24 years old and you answered NO to all questions in Step 1, please use your family taxable income to answer the following questions.

If you are at least 24 years old or you answered YES to any question in Step 1, please use only your taxable income.

Federal Low-Income Guidelines
Federal Low-Income Guidelines
Were you 24 years old or older as of December 21 of last year?
Total number of persons in household
What was the last calendar year taxes were filed
Indicate your family's federal taxable income for the prior year. *
I attest that my family did not file a federal income tax return for the last calendar year. Please complete the NON-TAX FILER STATEMENT form (available in the TOP office).
Have you applied for Financial Aid for the current academic year?
FAFSA application on (month/year):
I hereby certify, to the best of my knowledge, that all the information submitted is complete and correct. I understand that the information that I provide the Transfer Opportunity Program (TOP) will be kept confidential and follow the rules and policies of Umpqua Community College. I authorize the TOP to obtain, copy, and/or review my educational and financial records as needed. I understand that failure to disclose accurate information may be grounds for dismissal from the program. I also give the TOP permission to give my name, address, transcript, and the information in this application to other educational institutions or organizations that may be interested in providing me with educational or financial opportunities upon my acceptance/enrollment into the program. 

Sign and Submit

If you are less than 24 years old and you answered NO to all questions in Step 1, both you and a parent or a guardian, must sign below. 

If you are at least 24 years old or you answered YES to any question in Step 1, only your signature is required.

Applicant Signature *
Please select a signature verification type.
Parent or Guardian Signature
Please select a signature verification type.