Southern Oregon University-SSS

SUCCESS AT SOUTHERN/TRIO STUDENT SUPPORT SERVICES (SSS) PROGRAM REFERRAL

Referred by*

First NameLast Name

SOU Office (if applicable)

Institution or Organization (different to SOU)

Contact Phone

(999)999-9999

Email*

example@example.com

Referred Student Name

First NameLast Name

SOU Student ID (if you know it)

Student's Email

example@example.com

Student's Contact Phone

(999)999-9999

Who is eligible to be part of Success at Southern/TRIO SSS Program?

Please select all the information that apply:

Requirements (Must meet ALL – SSS Regs 646.3)

	Yes	No	Do Not Know
Is a Citizen or national of the United States, or meets the residency requirements for Federal Student Financial Assistance (grants, work-study and or loans - determined by FAFSA form).
Is Enrolled at Southern Oregon University.
Has a need for academic support in order to pursue successfully a postsecondary educational program. (This criteria is broadly defined, and may include but not limited to low GPA, low entrance or placement test scores, a need for assistance in completing college level math course, and/or being a transfer student or nontraditional student, among others).

Eligibility Criteria (Must meet at least ONE - SSS Regs 646.3)

	Yes	No	Do Not Know
First generation college student (the parents or person that raised you does not have a bachelor’s degree);
Low-income per federal guidelines (means an individual whose family’s taxable income for the preceding year did not exceed 150 percent of the poverty amount – according with yearly Federal TRIO Programs Low Income Levels) OR
Documented disability

Important information that would be useful for this referral (Do not provide sensitive and personal information of the referred student)