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.

Student Information
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
U.S. Citizen

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
EDUCATIONAL ASSESSMENT
Major(s)
Minor(s)
Classification

FreshmanSophomoreJuniorSeniorTransfer StudentNew FreshmanReturning Freshman
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
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

ACADEMIC NEEDS ASSESSMENT