Southern University-New Orleans-SSS-Application Form

SOUTHERN UNIVERSITY AT NEW ORLEANS
STUDENT SUPPORT SERVICES APPLICATION
Please answer all questions
SUNO Cohort Year*
The academic year you entered SUNO
SSS Cohort Year*
The academic year you entered SSS

Household Information
Name of Head of Household (if other than yourself)*

First NameLast Name
Relationship*

ParentGuardianOther
Occupation*
Are you in the foster care system?*

YesNo
Are you aging out of the foster care system?*

YesNo

Household Size (including self)*

	Number of people
Adults
Children
Total

Size of Family Unit*

12345678
Family's Taxable Income, please retrieve taxable income information from your most recent federal tax returns*

$22,590$30,660$38,730$46,800$54,870$62,940$71,010$79,080
Has either of your parents received a high school diploma?
Mother*

YesNo
Father*

YesNo
Has either of your parents received a baccalaureate degree?
Mother*

YesNo
Father*

YesNo
Do you have a condition that may require reasonable accommodations to support your learning or participation in academic activities?*

YesNo
If yes, please explain*
If yes, is this condition documented with the SUNO Office of Disability Services?

YesNo

Financial Information
Are you a Dependent or Independent student?*

DependentIndependent
Dependent Student Income Verification

I hereby certify that the financial information provided on the Student Support Services Application is accurate, to the best of my knowledge.
Parent or Legal Guardian's Signature*

Clear
Witness' Signature*

Clear
Date*

MonthDayYear
Date
Print Student's Name*

First NameLast Name
Independent Student Income Verification

I hereby certify that the financial information provided on the Student Support Services Application is accurate, to the best of my knowledge.
Student's Signature*

Clear
Witness' Signature*

Clear
Date*

MonthDayYear
Date
Print Student's Name*

First NameLast Name
Please upload most recent tax information (Tax returns) In lieu of a federal tax return, an SSI benefits letter or a self-declaration that you are not required to file taxes can be submitted. Please note: Applications without this submission are considered incomplete.*

Browse Files

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Student Needs Assessment

Have you participated in any of the following programs?*

	Yes	No
Educational Talent Search
Upward Bound
Educational Opportunity Center
Honoré Center

Intended Major*
Are you interested in pursuing a Master’s or doctoral degree?

YesNo
Needs Assessment Form (Initial Selection - please only choose one)*

Low high school gradesLow admission test scoresPredictive indicatorDiagnostic testsHigh school equivalencyLimited English proficiencyLack of educational and/or career goalsLack of academic preparedness for college level course workNeed for academic support to raise grade(s) in required courses(s)/academic major
Student Analysis: Check the items which describe your college needs*

Understanding the English LanguageAdjusting to college lifeReceiving more information about financial aidLearning more about myselfSolving personal problemsDeveloping inter-personal skillsChoosing a major and/or careerDeveloping note-taking and study skillsHelp in utilization of the LibraryTutoring Assistance (Specify subject below)Attendance of cultural enrichment activitiesServices appropriate for my physical disabilityOther
I need tutoring assistance in*

MathReadingWriting
How did you hear of the Student Support Services (SSS) TRIO Program?
I certify that the information provided on this application is accurate to the best of my knowledge; that I am 18 years of age or older; and that I am a first-generation college student (neither of my parent(s)/guardian graduated from a four-year post-secondary institution), I am from a low-income household, and/or I have a documented disability. I also certify that the financial information provided on this application is accurate to the best of my knowledge and that Student Support Services has my permission to receive copies of my financial and academic records. (If under the age of 18, a parent or guardian must sign below.)
Student's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent's or Guardian's Signature (if under the age of 18)*

Clear
Witness*

Clear
American College Test (ACT) scores and/or academic transcripts indicate that the applicant will need academic support to successfully pursue a Post-secondary educational program. This student, with the supportive services provided by the program, has the academic potential to earn a Bachelor’s degree.
Academic Coach's Signature

Clear
Date

MonthDayYear
Date
Director's Signature

Clear
Date

MonthDayYear
Date