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What is your full name?
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Birthdate (mm/dd/yy):
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Email Address:
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What is your local address? List street, city, state, and zip code.
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What is your home address? List street, city, state, and zip code.
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Local/Primary Telephone Number:
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Other Phone Number(s):
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Gender:
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Male
Female
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College Status:
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Freshman
Sophomore
Other
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Ethnic Background:
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Hispanic/Latino Descent
White
African American/Black
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
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Are you any other ethnicity other than what is listed above?
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Are you an orphan, or are (were) you (until age 18) a ward/depdendent of the court?
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Yes
No
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Are you an U.S. Citizen?
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Yes
No
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Are you a veteran?
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Yes
No
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Which of the following has been completed?
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Graduated from High School
Received GED
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Please list the Month and Year of your High School graduation or completion of GED.
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Were you a member of Upward Bound or Talent Search?
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Yes
No
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Do you qualify for financial assistance (Pell Grants, loans, scholarships, etc.)?
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Yes
No
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If you answered yes to the above question, please explain.
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What is your marital status?
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Married
Divorced
Separated
Single
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Are you a dependent or independent student? (Please use same status that was used for Financial Aid applications).
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Dependent
Independent
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If you are a dependent student what was your parent's and your income for 2011?
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If you are an independent student what was your income for 2011?
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How many are in your family?
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Do you have a physical or documented disability which requires special accomodations to help you succeed academically?
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Yes
No
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If yes, specify below:
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Has either of your parents/guardians received a bachelor's degree?
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Yes
No
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Father's Education: (Select highest level completed)
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Mother's Education: (Select highest level completed)
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First Generation College Student
Definitions-For the purpose of this chapter:
(1)First Generation College Student.-The term "first-generation college student" means-
a. An individual both of whose parents did not complete a baccalaureate degree; or
b. In the case of any individual who regularly resided with & received support from only one parent, an individual whose only such parent did not complete a baccalaureate degree.
Under this defintion are you a "First Generation College Student"?
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Yes
No
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In which of the areas listed below do you need assistance?
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Selecting a career
Study Skills
Writing
Computer Training
Learning about college majors
Note Taking
Math
Personal Counseling
Writing a resume
Test Taking and Memorizing
Managing Time
Job Interviewing
Reading
Financial
Other
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What is your major?
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Are you undecided on a major?
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Yes
No
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Do you plan to transfer to another college?
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Verification of Information:
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By checking this box I verify this information is accurate to the best of my knowledge.
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I understand the SSS Program will use the data provided on this form to assist in assessing any academic and/or career planning needs & all of the information will be kept confidential. I release the following information to the SSS staff: high school transcripts, SAT/ACT/Compass scores, instructor evaluations, financial assistance award notices & income information, vocational rehab. records, disability services records & any other information from my academic records pertaining to enrollment in SSS.
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I certify the information on this application is true and correct to the best of my knowledge and by submitting this application I allow SSS program to use this information.
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