Student Support Services Application
www.ncmissouri.edu/sss Geyer Hall 103 – Academic Year 2018-2019
Please download, print and complete this form. Incomplete applications will not be considered. If you have questions, feel free to contact our office at (660) 359-3948 ext. 1348. Return completed applications to Geyer Hall 103.
Information in this form is for the Student Support Services program only and is in no way considered in your admission status at NCMC. This application is also NOT a general admission application form.
(First, Middle, Last)
Graduated High School _____/______(Month/Year)
Received GED _____/______(Month/Year)
College Credit Earned:
Less than 30 credits
Between 30-60 credits
More than 60 credits
Please check either “YES” or “NO” for each.
|American Indian or Alaskan Native|
|Native Hawaiian or other Pacific Islander|
Are you Hispanic or Latino descent?
Are you an orphan, or are (were) you (until age of 18) a ward/dependent of the court?
Citizen-check only one:
U.S. Citizen No Permanent Resident Other
Are you a veteran?
Were you in Upward Bound or Talent Search?
Have you ever been served by Student Support Services at NCMC or another institution?
Do you have a physical or documented disability which requires special accommodations to help you succeed academically? Yes (continue answering questions below) No (move to next section)
Yes (continue answering questions below) No (move to next section)
If yes, please specify:
Have you applied for accessibility services (requested accommodations)?
Education & Career Goals
AA (Associate in Arts, Transfer)
AAT (Associate in Arts, Teaching)
AAS (Associate in Applied Science)
Not degree seeking
What is your academic area of interest?
Will you transfer to another college?
If yes, where would you like to transfer?
Possible career interests:
Check if unknown
Areas of Need
(Please check any areas in which you need assistance.)
selecting a career
selecting a major
What barriers or concerns do you have when it comes to pursuing your education?
How did you hear about us?
Have you applied for Financial Aid for the current academic year (FAFSA completed for 2018-2019)?
Do you receive Financial Aid?
What aid do you receive?
Married Divorced Separated Single
Are you a Dependent or Independent student?
Independent student-> What was your Combined taxable income for 2017?
Dependent student-> What was your Combined taxable income for 2017?
-> What was your parent’s taxable income for 2017?
How many are in your family, including yourself?
Note: Do not report “adjusted gross income.”
(check highest level completed for each parent)
|Parent 1 Education||Parent 2 Education|
|Less than high school||Less than high school|
|High School Graduate||High School Graduate|
|Some College||Some College|
|Associates Degree (2 year)||Associates Degree (2 year)|
|Bachelors Degree (4 year)||Bachelors Degree (4 year)|
|Graduate Degree||Graduate Degree|
According to Student Support Services CFR Part 646.7: First Generation College Student means:
- A student neither of whose natural or adoptive parents received a baccalaureate degree;
- A student who, prior to the age of 18, regularly resided with and received support from only one parent and whose supporting parent did not receive a baccalaureate degree; or
- An individual who, prior to the age of 18, did not regularly reside with or receive support from a natural or adoptive parent.
Parents of dependent students must verify the following
All of the information on this form regarding my taxable income and level of education is true and complete to the best of my knowledge.
(Parent Signature, Date)
Students must verify and accept the following:
Student Clearance amp; Approval: I understand that the Student Support Services program will use the data provided on this form to assist in assessing my academic and/or career planning needs and that all of the information will be kept confidential. I release the following information to the SSS staff: high school transcripts, SAT/ACT/COMPASS/ACCUPLACER/Nelson Denny scores, instructor evaluations, financial assistance award notices and income information, vocational rehabilitation records, disability services records and any other information from my academic records pertaining to my enrollment in SSS. I certify that the information on this application is true and correct to the best of my knowledge.
First Generation College Student: Per the above definition, the following is true to the best of my knowledge:
Yes, I am a First Generation College Student No, I am not a First Generation College Student
Taxable Income: Income information on this form is true and complete to the best of my knowledge.
(Student Signature, Date)