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 *
Home Phone
Cell Phone Number
Email Address *
Intended field of study/major at Umpqua Community College *
Intended field of study/major at 4-year college/university *
Professional/Career Goal *
Ethnicity (optional): Do you identify as Hispanic or Latino?
Race (optional):  Check all that apply
American Indian/Alaskan Native
Pacific Islander
Do you plan to transfer to a 4-year college/university? *
Are you a U.S. Citizen?
If No, enter your Permanent Resident Alien # (if applicable):
Are you currently enrolled in at least 12 credit hours at UCC? If no, number enrolled:
Has your mother/guardian received/earned a Bachelor's Degree from a 4-year college/university?
If yes, did you regularly reside and receive support from this parent/guardian?
Has your father/guardian received/earned a Bachelor's Degree from a 4-year college/university?
If yes, did you regularly reside and receive support from this parent/guardian?
One of our eligibility criteria is having a documented physical or learning disability. Please indicate whether you would like to discuss this possibility with program staff.

Income Verification

 The following questions will help the Transfer Opportunity Program determine if you meet federal low income guidelines.  Documentation of taxable and non-taxable income will be required for verification.

Were you 24 years old as of December 21 of last year?
A. Total number of persons in household
B. Last calendar year taxes were filed
C. Family's federal *taxable income

*Note:  Your taxable income can be found on the federal income tax return you filed for the last calendar year.  


If you did not file a federal income tax return for the previous year, please indicate below:

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).
Financial Aid Information
Have you applied for Financial Aid for the current academic year?
If no, when will you apply (month/year)?
If yes and you have received your award letter, what type of aid will or have you received?  (Please check all that apply)
Pell Grant
State Need Grant / Oregon Opportunity Grant
Work Study
Scholarship(s) - list below
Unsure of aid - as I have not received my award.
FAFSA application on (month/year):

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.

Academic Advising: assistance with choosing the correct classes for your selected program
Career Counseling: assistance in exploring career options and professional opportunities
Financial Aid Advisement: assistance in obtaining financial/scholarship information
Campus Visits: campus visits to Oregon universities/colleges campuses
Social/Cultural Activities: activities to expand social/cultural experiences, otherwise unaffordable
Peer tutoring: assistance with challenging course(s) to increase or maintain/increase grade point average
Transfer Assistance: assistance with transferring successfully to a 4-year university/college
Personal Counseling: assistance with personal issues
Mentoring: peer and staff mentoring
Educational Workshops/Seminars: to assist with educational goals and academic progress
What other help or support do you feel you may need to successfully transfer from UCC to a 4-year college/university?
Have you ever participated in a TRiO or UCC Program? (Please check all that apply)
Educational Talent Search - TRiO
Upward Bound - TRiO
Student Support Service - TRiO
Bridge Program
Educational Opportunity Program - TRiO
Jump Start
College Now
Dual Enrollment
Adult High School Diploma
Woolley Center - High School Diploma
GED Program
Other (write below)
How did you hear about the Transfer Opportunity Program?

Sign and Submit
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. 
Applicant Signature *
Please select a signature verification type.