Iowa Western Community College is committed to providing equal educational opportunity and forbids unlawful discrimination on the basis of race, color, creed, religion, national or ethnic origin, ancestry, genetic information, physical or mental disability, age, sex, sexual orientation, gender identity or expression, pregnancy, marital status, veteran status, AIDS/HIV status, citizenship, or medical condition, as those terms are defined under applicable laws.

Student Information:
Last Name *
First Name *
Middle Name
Gender *
Student ID:
Date of Birth *
Social Security Number *
Permanent Address: *
Address 2:
Permanent City *
Permanent State *
Permanent Zip *
Cell Phone Number: *
IWCC Email Address: *
What is the best way to contact you? *
Who would you like to list as an emergency contact?
Emergency Contact Phone Number:
Do you plan to live on campus? *
Race/Ethnicity: (Please select all that apply)
African American/Black
Native Hawaiian or Pacific Islander
Native American/Alaskan
Prefer not to disclose

Academic Information:
What is your current grade level in college? *
What is your current enrollment status (credits)? *
Have you attended another college previous to attending Iowa Western Community College? *
If yes, where?
How many college credit hours have you completed so far? *
What is your current program of study? *
Do you have an intent to transfer to a 4 year institution upon graduating from IWCC? *
If so, which college(s) are you considering?
Please tell us about your career goals. *

Eligibility Information:

The following information is used to determine eligibility for TRiO/Student Support Services, which is federally funded by the Department of Education and requires that we report statistics about the students we serve.  Applicants are required to complete this section.

Are you a United States citizen? *
If no, are you a permanent resident of the United States?
What is your highest level of education? *
To better assist you, please select which of the following options that best reflects your top academic need: *
What what are the biggest obstacles that may prevent you from graduating from Iowa Western Community College? *
Would you like to use accommodations while attending IWCC? *
Please note: In order to receive accommodations, you must have had a 504 or IEP in high school or have a documented disability on file with IWCC.
Have you applied for (FAFSA) student financial aid? *
If you have not filed your FAFSA, please upload a copy of the first 2 pages of your 2019 1040 tax return for review:
Does your parent(s) or guardian(s) have a bachelor degree? *

Information received on this application will be held highly confidential. The application and any part of its contents will not be released to anyone other than program staff without a written statement from you.
All of the information on this application is true and accurate to the best of my knowledge. I understand that the college reserves the right to admit or deny any student enrollment in the TRiO/SSS program. Completion of application does not guarantee acceptance into program.
Please note, by signing this application you are agreeing to:


1. If accepted into the program, I allow my name and/or picture to be printed in any TRiO newsletter, publication, social media, or display in recognition of academic success, leadership, or graduation.

2. I also agree to meet with my TRIO advisor at least once each semester and notify the program if my contact information changes or I change my academic program.
3. As a participant of the TRIO program, I also give permission to discuss issues related to my academic progress with any instructor and/or staff for the purpose of coordinating academic and personal support services (as long as I remain an active participant of the program).

Student Signature:
Student Signature *
Please select a signature verification type.
By typing your full name, you are providing your electronic signature to this application.

The TRiO/SSS staff reserves the right to deny admission to the program even if you meet the criteria for eligibility. You may be denied admission to TRiO/SSS if you: · Have a history of very poor academic performance · Demonstrate an erratic enrollment pattern · Already have an associate’s degree or higher · Are disrespectful or abusive to TRiO staff or students · If there are no slots available · Other circumstances on a case by case basis.