CSS Intake Form
Intake forms are evaluated periodically throughout the semester. Should you be selected for participation, you will be notified via KCC email. If you have questions, contact the Center for Student Success at 269.965.4150 or css@kellogg.edu.
Personal Information
First Name
Last Name
kID
Street Address
PhoneNumber
City
State
ZipCode
Program of Study
First Name
k-ID or Date of Birth
Phone Number
City
State
Zip Code
Program of Study
U.S. Citizen:
Date of High School Graduation or GED
Last Name
Street Address
No
Yes
Out-of-workforce
English as a second language
Single Parent / Single pregnant woman
Academically disadvantaged
None of the above
Homeless Individual
Youth who are in , or have aged out, of foster care
Low Income
Disability
For additional assistance and potential funding:
Yes
No
No
Yes
2. Has either your mother or father received a four-year degree from a college or university?
1. Are you planning to transfer to a four year institution Immediately upon leaving KCC?
* The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount. see chart below
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Date of Graduation
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Family units with more than 8 members, add the amount for each additional member.
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$7,710
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By clicking SUBMIT you state that:
The information provided is accurate to the best of my knowledge. I understand that I may be eligible for a
Center for Student Success program based on the information I provided.
Submit
* FEDERAL LOW-INCOME LEVELS
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