Elizabeth City State University-SSS-Application Form

Elizabeth City State University
Elizabeth City, North Carolina 27909

TRIO STUDENT SUPPORT SERVICES PROGRAM
STUDENT APPLICATION

Student Support Services Program provide undergraduate students with the academic support needed to increase persistence, improve academic standing, graduation rates, and post baccalaureate enrollment.
- Name*
  
  First NameMILast Name
- Student ID Number
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Campus or Current Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- ECSU Student Email Address*
  example@example.com
- Home/Cell Phone
  (999)999-9999
- Alternate (Personal) Email Address:
  example@example.com
- T-Shirt Size
- Permanent Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Gender
  
  MaleFemale
- Are you a U.S. Citizen or a permanent resident?
  
  YesNo
- Race/Ethnicity (For statistical purposes only)
  
  American Indian Alaskan NativeAsianAfrican American BlackHispanic LatinoWhiteNative Hawaiian Pacific Islander
- EMERGENCY CONTACT INFORMATION
- Name
  
  First NameLast Name
- Phone Number
  (999)999-9999
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Relationship
- Academic Information
- Major(s)
- Minor(s)
- Classification
  
  First YearSecond YearThird YearFourth YearOther
- Program Assessment
- Have you previously participated in any of the following programs? (lf yes, please check which one)
  
  Upward BoundTalent SearchGear UpStudent Support Services (SSS)Education Opportunity Center (EOC)
- At what school or institution?
- ELIGIBILITY INFORMATION
- Name of Mother/Guardian
  
  First NameLast Name
- Mother's Highest Education
  
  High SchoolSome CollegeBachelor'sMaster'sDoctorate
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Name of Father/Guardian
  
  First NameLast Name
- Father's Highest Education
  
  High SchoolSome CollegeBachelor'sMaster'sDoctorate
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Parent/Guardian Education/Information
- Please indicate the level of education completed. Check “Yes” only if you have completed the indicated degree. If you have started a degree, but not completed it, then check “No.”
- Relationship to Applicant and Name
- Mother’s Name/Guardian:
  
  First NameLast Name
- Adress
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- High School Diploma or GED
  
  YesNo
- 2 Year College Degree
  
  YesNo
- 4 Year College Degree
  
  YesNo
- Father’s Name/Guardian:
  
  First NameLast Name
- Adress
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- High School Diploma or GED
  
  YesNo
- 2 Year College Degree
  
  YesNo
- 4 Year College Degree
  
  YesNo
- FIRST GENERATION STATUS
- Did either your biological or adoptive parent with whom you resided with before turning 18 have a 4-year college degree?
  
  YesNo
- Accessibility (Disability ) Information
- (Optional) Are you registered with the ECSU Office of Disability Services?
  
  YesNo
- (Optional) Do you receive accommodations at ECSU?
  
  YesNo
- (Optional) Do you believe you have a mental, physical, or learning disability, or do you identify as a student with disability?
  
  YesNo
- INCOME VERIFICATION
  
  Documentation of household size and taxable income is required to determine eligibility for participation in TRIO programs. All information is kept confidential.
- Please select the response that applies to you.
  
  I am a Dependent Student (younger than 24, unmarried or emancipated; parental income is reported on the FAFSA).I am an Independent Student (typically age 24 or older, married or emancipated; parental income is not reported on the FAFSA)
- I am a Dependent Student (younger than 24, unmarried or emancipated; parental income is reported on the FAFSA)
  
  I am an Independent Student (typically age 24 or older, married or emancipated; parental income is not reported on the FAFSA)
- Total number of persons (including yourself) in your family:
- Have you filed for financial aid this year?
  
  YesNo
- Did you receive a Pell Grant?
  
  YesNo
- How are you paying for your education? (Check all that apply)
  
  Pell GrantWork StudyLoanSelfNC WorksEmployerParent/GuardianVa LoanVocational RehabilitationOther
- INCOME INFORMATION
  
  The United States Department of Education requires that the Student Support Services staff gather this data to determine student eligibility. The personal information you provide to the Student Support Services Program will be kept confidential and is protected by the Privacy Act.
- Verify the number of people in your household
- What was the household's taxable income? Check the one that applies:
  
  $0-$23,475$23,476-$31,725$31,726-$39,975$39,976-$48,225$48,226-$56,475$56,476-$64,725$64,726-$72,975$72,976-$81,225$81,226-above
- *Taxable income is the final income after all credits and deductions have been applied.
- Parent/Guardian’s Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- READ THE FOLLOWING STATEMENT AND SIGN
  
  I agree that the information on this application is correct to the best of my knowledge. lf any information changes on this form while I am a part of this program, I will notify the Student Support Services Progam immediately. I understand that in order for the Student Support Services Program to accurately assist me, I will be honest in communicating all my information that may be needed.
- Applicant Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Personal Statement: Please write a brief statement of your personal goals and career aspirations, as well as the most likely complication that might delay your graduation.
- Below is a list of services available through Student Support Services. Please check any services you would find beneficial to your academic success.
- Academic Skills
  
  Time ManagementStudy SkillsTest TakingTest AnxietyReading SpeedReading ComprehensionEssay WritingResearch WritingCritical ThinkingVocabularyOrganizationProofreadingSpellingNote TakingBasic Computer SkillsBasic Math Skills (Developmental Math, College Algebra)Advanced Math Skills (Any Math Course Above College Algebra)TypingPeer or Group TutoringLearning Strategies
- Career Exploration
  
  Interest Testing/Career ChoiceChoosing a MajorCareer informationAcademic AdvisingResume DesignlnterviewingJob SearchGraduate School AdvisingOther
- Personal Assistance
  
  Goals and Decision MakingProblem SolvingFinancial Aid AdvisingPersonal SupporlOther
- Can you think of anything that might keep you from completing your degree? (Family, grades, social life, money, self-motivation, career decision, other-please explain)
- ACADEMIC NEEDS ASSESSMENT
  
  Confidential – For Program Use Only
- Purpose:
  The TRIO Student Support Services (SSS) program is committed to supporting your academic success, personal development, and college completion. Please complete this short needs assessment to help us tailor services to best meet your needs.
  
  Section 1: Academic Preparedness and Support Needs
- 1. In which areas do you feel you need academic assistance? (Check all that apply)
  
  Reading comprehensionEssay writing and editingResearch and information literacyTime management and organizationNote-taking or study skillsTest-taking strategiesMathScienceOther
- Math (specify course or topic):
- Science (specify course or topic):
- 2. How confident are you in your ability to succeed academically at your college?
  
  Very confidentSomewhat confidentNeutralSomewhat unconfidentNot confident at all
- 3. Have you used any of the following TRIO SSS services so far? (Check all that apply)
  
  Academic advisingTutoringFinancial literacy workshopsCareer exploration/planningTransfer assistancePeer mentoringCultural or enrichment activitiesI have not yet participated in services
- Section 2: Challenges and Barriers to Success
- 4. What challenges currently affect your academic success? (Check all that apply)
  
  Financial stressEmployment/work hoursFamily responsibilitiesTransportation or housing issuesHealth or mental health concernsLack of motivation/focusDifficulty understanding course contentLimited access to technology/internetOther
- Section 3: Service Interests & Follow-Up
- 5. Which TRIO services would you like to participate in this semester? (Check all that apply)
  
  Weekly or biweekly tutoringAcademic coaching/study skills workshopsOne-on-one time management sessionsFAFSA assistance and financial aid guidanceScholarship search or essay supportGraduate school prepLeadership or educational enrichment eventsMental wellness support/referral
- 6. Is there anything else you would like us to know about your academic needs or goals?
- READ THE FOLLOWING STATEMENT AND SIGN
  
  I agree that the information on this application is correct to the best of my knowledge.
- Applicant’s Signature
  
  Clear
- Date
  
  MonthDayYear
  Date

FIRST GENERATION STATUS

Accessibility (Disability ) Information

INCOME VERIFICATION

ACADEMIC NEEDS ASSESSMENT