Student Support Services Application

www.ncmissouri.edu/sss Geyer Hall 103 – Academic Year 2019-2020


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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.

Printable PDF Version

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.

Demographic Data

Name:


(First, Middle, Last)
DOB:


Local Address:


Home Address:


SS#:


NCMC ID#:


Cell#:


Home#:


Choose one:

Graduated High School _____/______(Month/Year)
or
Received GED _____/______(Month/Year)

College Credit Earned:

 Less than 30 credits
 Between 30-60 credits
 More than 60 credits

Gender

 Female
 Male
 No response

Race/Ethnicity

Please check either “YES” or “NO” for each.

Yes No
White
African American/Black
Asian
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander

Are you Hispanic or Latino descent?
 Yes No

Citizen/Program Information

Are you an orphan, or are (were) you (until age of 18) a ward/dependent of the court?
 Yes No
Citizen-check only one:
 U.S. Citizen No Permanent Resident Other
Are you a veteran?
 Yes No
Were you in Upward Bound or Talent Search?
 Yes No
Have you ever been served by Student Support Services at NCMC or another institution?
 Yes No

Disability Information

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)?
 Yes No

Education & Career Goals

 AA (Associate in Arts, Transfer)
 AAT (Associate in Arts, Teaching)
 AAS (Associate in Applied Science)
 Certificate Only
 Not degree seeking
 Unknown

What is your academic area of interest?


Will you transfer to another college?
 Yes No
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.)

 math
 study skills
 test taking
 note taking
 computer training
 resume writing
 time management
 personal counseling
 job interviewing
 writing
 financial
 reading
 selecting a career
 selecting a major
 Other

What concerns or barriers do you have when it comes to pursuing your education?




How did you hear about us?


Income Eligibility

Have you applied for Financial Aid for the current academic year (FAFSA completed for 2018-2019)?
 Yes No
Do you receive Financial Aid?
 Yes No
What aid do you receive?
 Pell Grants
 Loans
 Voc Rehab
 Other


What is your marital status?
 Married   Divorced   Separated   Single
Are you a Dependent or Independent student?
 Dependent   Independent
Independent student-> What was your Combined taxable income for 2018?


Dependent student->Complete the “Dependent Verification Form” if you provide parent financial information on your FAFSA.


->How many are in your family, including yourself?


Finding Taxable Income
Form Line Number(s)
1040 10 on 2nd page

Note: Do not report “adjusted gross income.”

First Generation

(check highest level completed for each parent)

Parent 1 Education Parent 2 Education
 Unknown  Unknown
  Less than high school  Less than high school
  GED  GED
 High School Graduate  High School Graduate
 Some College  Some College
 Certificate  Certificate
 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:

  1. A student neither of whose natural or adoptive parents received a baccalaureate degree;
  2. 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
  3. An individual who, prior to the age of 18, did not regularly reside with or receive support from a natural or adoptive parent.

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 understand that my Social Security Number (SSN) is collected only for use in verifying my enrollment at my transfer school via the National Student Clearinghouse. 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)


(Print Name)