University of North Carolina at Pembroke-SSS-Application Form

University of North Carolina at Pembroke

TRIO Student Support Services (SSS)

2024-2025 Student Application

Name*

First NameMiddle InitialLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip

Phone #*

(999)999-9999

Email (Bravemail only)*

example@example.com

Banner*

DOB*

mm-dd-yyyy

Gender Identity*

Race/Ethnicity*

First Date of Enrollment at UNCP*

Are you a transfer student?

YesNo

Current Classification*

Freshmen (never attended college)Freshmen (attended some college before)Sophomore (30-59 earned credit hours)Junior (60-89 earned credit hours)Senior (90 and up earned credit hours)

If you already have a Bachelor’s Degree, you are not eligible to participant in TRIO SSS.

ELIGIBILITY INFORMATION

Students may establish eligibility based on taxable income, status as a first-generation college student, or a documented disability. All information will be verified by Office of Financial Aid and/or Accessibility Resource Center (ARC).

Are you a first-generation college student? (Your parent(s)/legal guardian(s) DID NOT COMPLETE A BACHELOR’S DEGREE before you turned 18.)*

YesNo

Have you completed the FAFSA?*

YesNo

Have you received Federal Pell Grant?*

YesNo

Do you have a documented disability?*

YesNo

If yes, are you registered with Accessibility Resource Center (ARC)?

YesNo

Use information based on your federal tax returns or your parents’ federal tax returns (if you are a dependent) to answer the following questions.

What is the total number in your household?*

What is your family taxable income (line 11b of tax form 1040)?*

STUDENT NEEDS ASSESSMENT

Please identify your academic needs by checking the boxes below.*

Please select one (1) entry below to describe your biggest need for Student Support Services (SSS)*

Please check all services you are most interested in receiving.*

Academic Support: Study skills, time-management, writing, reading comprehension, math, science, note-taking, tutoring, otherAcademic Advising: Understanding degree plan, communicating with advisor, changing major, academic policies, registering for classes, otherFAFSA/Financial Literacy: Completing the FAFSA, understanding award letter, finding loans/grants, understanding student loans, budgeting and saving, investments, checking accounts, otherCareer Planning: Career interests, finding a job, resume writing, interviewing, completing job applications, writing cover letters, professional/employability skills, internships, otherPersonal Development: Stress management, transitioning to college, finding a sense of belonging, joining clubs/organization, family issues, excessive worrying, otherCultural Enrichment: Diversity awareness, handling cultural issues, understanding others, etc

Provide any other information to help TRIO SSS determine your needs and how the program can assist you.

Student Signature*

Date Signed*

mm-dd-yyyy

Parent Signature (If under 18 years old)

Date Signed

mm-dd-yyyy