SURGE | Triton College

* = required fields

Semester * Fall 2019

Student Contact Information

First Name *

M.I.

Last Name *

Address *

Apt#

City *

State*

Zip Code *

Phone Number (Preferred for contact) *

Triton Email Address *

Student Demographic Information

Triton Colleague ID *

Date of Birth *

Racial Identity *

Student Education Information

High School Attended *

Colleges/Universities Attended *

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? *

Are you a PELL Grant recipient? *

Student Military Information

Serving active duty in the armed forces? *

Student Response

Please provide short responses to the following questions:

Why do you want to participate in this mentoring program? *

What do you hope to gain from joining SURGE? *

Please explain any scheduling issues that may prevent you from attending weekly workshops and meetings with your advisor/mentor. *

What are your hobbies/interests? *

Student Verification

By signing this application, I attest that all the information on this application is true and accurate. I authorize the release and disclosure of official school records to SURGE; understanding that the information in these records will be used only to assess need for program services, including referral for financial assistance, but not limited to scholarships, federal financial aid, work study, monitoring educational progress, evaluate the effectiveness of program activities, and fulfill program reporting requirements. I also allow SURGE and Triton College to use my image for program promotional purposes.

Verification Confirmation *(represents electronic signature)

Date *

In This Section

SURGE Application