Fayetteville State University-SSS

Fayetteville State University

1200 Murchison Road

Fayetteville, North Carolina 28301

(910) 672-1172

sss@uncfsu.edu

TRIO STUDENT SUPPORT SERVICES

Student Support Services is a federally funded program that provides academic support services to a student meeting the grant guidelines. To be eligible for the program, you will need to demonstrate an academic need and provide the following: your taxable income from your 1040 tax documentation. All information provided will be held confidential and used for the TRIO SSS program purposes only.

ALL INFORMATION REQUESTED MUST BE COMPLETED FOR THE APPLICATION TO BE CONSIDERED.

NEEDS ASSESSMENT

Needs Assessment*

	Yes	No
1. I need to get better grades in college.
2. I need to develop stronger study skills and habits.
3. I need tutoring.
4. I need to learn how to set goals and make better decisions.
5. I need to understand how the courses I am taking relate to my career plans.
6. I need to better understand my interests, abilities, and other traits.
7. I need to learn about the correct academic classes that I should be taking to complete my degree.
8. I need assistance with financial aid and researching scholarships.
9. I need to get involved in positive activities, extra-curricular activities and or clubs or organizations.
10. I have thought about dropping out of college.
11. I am transferring from a community college or university this school year
12. I have been out of school for an extended amount of time.
13. I am interested in attaining a master's degree or higher degree after completing FSU.
14. I am currently sharing housing due to economic hardship or loss of housing, awaiting Foster Care placement, living in a Foster home, residing in a Group home or an emergency/transitional shelter.

If you indicated a need for tutoring please select which specific area(s):

ScienceMathEnglishHistoryOther
I have participated in one of the following:

Upward Bound Math & ScienceUpward BoundFind-A-FriendTalent Search21st Century Community Learning CentersBoys & Girls ClubEducational Opportunity CenterI don't know
I have participated in the following (check all that apply):

Upward Bound Math & ScienceUpward BoundFind-A-FriendTalent Search21st Century Community Learning CentersBoys & Girls ClubEducational Opportunity CenterGEAR UPStudent Support ServicesEarly CollegeRonald McNair ScholarsI don't know

MEDICAL INFORMATION
MEDICAL INFORMATION
Do you have a physical impairment, medical condition or disability?*

YesNo
If yes, then list:*
Do you take any type of medication?*

YesNo
If yes, then list:*
Do you have any allergies?*

YesNo
If yes, then list:*

DEPENDENCY INFORMATION
DEPENDENCY INFORMATION
Select one:*

IF UNDER 24 YEARS OF AGE, SINGLE, NO CHILDREN OR CHILDREN RECEIVING LESS THAN, PROVIDE YOUR PARENT'S TAXABLE ANNUAL INCOME ON THE MOST RECENT TAX RETURNIF OVER 24 YEARS OF AGE, MARRIED, A VETERAN OR ACTIVE MILITARY, HAVE CHILDREN WHO RECEIVE MORE THAN HALF OF THEIR SUPPORT FROM YOU, OR AN ORPHAN OR WARD OF THE COURT, PROVIDE YOUR TAXABLE ANNUAL INCOME ON THE MOST RECENT TAX RETURN

ELIGIBILITY INFORMATION
ELIGIBILITY INFORMATION
DO YOU HAVE AN ASSOCIATED DEGREE?*

YESNO
DID EITHER PARENT GRADUATE WITH A 4 YEAR DEGREE OR HIGHER?*

YESNO

INCOME VERIFICATION
If you DO NOT submit a copy of your completed income tax form (1040, 1040EZ, 1040A), you will need to complete the information below, which serves as a verification of your family income for last year.

*Taxable Income*: This information is located on tax forms (1040-line 43; 1040A-line 27; 1040EZ-line 6)

*DO NOT USE YOUR ADJUSTED GROSS INCOME*
I/my parent or guardian's taxable income for the last year was $__________ (Form 1040 Line 11b). Please note that taxable income is different from gross or net income.*
DO NOT USE YOUR ADJUSTED GROSS INCOME
Do you receive any of the following:*

Pell GrantWorkstudyScholarshipStudent Loans
How many individuals currently living in the household (including myself)?*
Certification

As evidence of my signature below, I hereby certify that all the information I have furnished is correct and true to the best of my knowledge.
Please answer the following questions. Your answers will help us assess your motivation and preparation for academic success.
1. What is your major?*
2. What are your academic goals?*
3. What are your academic concerns?*
4. How do you feel the SSS Program can assist you?*
Student Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Parent Signature (for dependent students under the age of 24)

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

STUDENT CONTRACT
Fayetteville State University

Student Support Services

Student Contract

I understand that the Student Support Services Program is a federally funded program, and that my selection to participate in the program is based on my meeting the federal eligibility criteria.
As a SSS Participant I agree...

To actively participate in the Student Support Services Program, which is designed to provide the following services: tutoring, counseling, academic support workshops, information regarding financial literacy, and graduate school preparation which will help me, achieve success during my tenure here at this institution.To meet with my assigned SSS Advisor at least 3 times a semester.To actively participate in SSS Workshops; attend at least 3 workshops each semester which will help me achieve my academic goals.To arrive on time to all scheduled tutoring sessions with prepared class assignments, textbooks, and notes for each tutoring session.To meet with my advisor during mid-term advisement to review my academic status.To give SSS permission to include me in photographs, films, publications, or interviews as they pertain to Student Support Services, and I understand that such pictures, films, or interviews may be used to promote or publicize Student Support Services' events and/or program.
I have read the above statements and understand that I will be put under a probationary period upon my initial intake into the program which may exceed two semesters of my enrollment at FSU.

I will adhere to the contract by signing below:
Student Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy