Submit Your Application

Thank you for your interest in our Student Support Services program at Malcolm X College! Please complete this application as thoroughly as possible. If you have any questions, please call our office at 312-850-7208 or email fcasillas@ccc.edu

General Information:

Last Name: *

First Name: *

Middle Name:

Address *

City: *

State: *

Zip Code: *

Cell Phone Number:

Email Address:

Student Demographic Information:

CCC Student ID Number *

Date of Birth *

Age

Gender *

Ethnicity *

Student Citizenship Information:

U.S. Citizen *

Permanent Resident *

Permanent Resident # (If Applicable)

First Generation Status Information:

Does your Mother have a Bachelor's (4-year college) degree? *

Does your Father have a Bachelor's (4-year college) degree? *

Which parent did you live with and receive support from until you were 18 years old? *

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Students With Diverse Needs:

Do you have a documented disability? *

If yes, please provide documentation to the Disability Access Center to discuss any accommodations that you may require.

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Student Information:

Currently enrolled this semester? *

Is MXC your home campus? *

Do you plan to transfer to a 4-year institution? *

Have you applied for financial aid? *

Size Of Your Family Household?- Include Yourself *

Have you already received an Associate's degree from CCC or another institution? *

Are you a Freshman (Less than 32 credits)? *

Are you a Sophomore (32 or more credits)? *

Check each area you would like assistance with:

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Academic Advising

Career Counseling

Class Scheduling/Registration

Goal Setting

Financial Aid Assistance

Financial Literacy

Motivation/Study Skills

Test Anxiety

Transfer Assistance

Tutoring

Consent:

PLEASE READ Terms of Submission:

I am willing to make the commitment to participate in Malcolm X College’s Student Support Services (TRiO) Program. I understand that I am required to attend orientation, a SSS workshop, and/or tutoring sessions. I need to meet with my SSS advisor throughout the semester. I give SSS (TRiO) permission to collect information about my participation in the program, including any information related to my enrollment in City Colleges of Chicago, understanding that this information may be used to develop statistical data for reports/publications, to evaluate the program, and to assess my academic and career needs.

All information will be kept confidential with the exception of the following:

A court of law orders the release of information.

You direct me to disclose information to another for consultation purposes.

May be of harm to myself or others.

By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.

Sign and Submit:

Applicant Signature *

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I agree to the terms included.