Coastal Alabama Community College-SSS-Application Form

SSS APPLICATION
Date*

MonthDayYear
mm-dd-yyyy
STUDENT #*
NAME*

FIRST NAMEMILAST NAME
ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
Check the campus that you will be attending.*

BrewtonAtmoreOnline
CELL NUMBER*
(999)999-9999
OTHER NUMBER
(999)999-9999
DATE OF BIRTH

MonthDayYear
mm-dd-yyyy
COASTAL E-MAIL*
example@example.com
GENDER*

MaleFemale
MARITAL STATUS

SingleMarriedDivorcedSeparatedWidow
Do you have children or other dependents who receive more than half of their support from you? (Not including your spouse)*

YesNo
U.S. CITIZEN*

YesNo
Are you Hispanic or Latino?*

YesNo
ETHNICITY*

WhiteBlack/African AmericanAsianHispanicAmerican Indian/Alaskan NativeNative Hawaiin/Pacific Islander
Do you have a disability?*

YesNo
Does this disability require special accommodations?*

YesNo
CLASSIFICATION

FreshmanSophomore
MAJOR
Do you plan to transfer to a four-year school after graduation?

YesNo
Which parent (natural or adopted) did you regularly reside with until 18 years of age and receive support?

FatherMotherBoth ParentsNeither Parents
Has your mother (natural or adopted) received a 4-year college degree?*

YesNo
Has your father (natural or adopted) received a 4-year college degree?*

YesNo
Have you previously participated in any of the following TRIO programs: (select all that apply)

Upward BoundVeterans Upward BoundTalent SearchStudent Support ServicesEducational OpportunityNONE
Please indicate how we may be of assistance: (Mark all that apply)

Academic Support/InstructionStudy Skills (Note Taking/Test Taking)Assist Course SelectionApplying for Federal Student AidAcademic Advising/Degree PlanningCareer CounselingTransfer CounselingOne On One TutoringGroup TutoringInformation on Federal Student AidApplying to GraduateApplying to a 4 year College

Please answer the following questions to help us evaluate how Student Support Services can best help you reach your academic goals.

	STRONGLY AGREE	AGREE	INDIFFERENT	STRONGLY DISAGREE	NOT APPLICABLE
I am uncertain about my career goals.
I need more social and academic support.
I do not have adequate computer skills.
I miss information that is presented during class.
I am reluctant to ask for help.
I have difficulty finding time to study.
My family is supportive of me attending college.
I know where to find personal, financial, and academic support on campus.

Needs Assessment

TRIO SSS uses this needs assessment to best serve students. The information is kept strictly confidential. Honest answers help TRIO SSS best meet your needs, but feel free to withhold personal information if you are not comfortable disclosing. There are no right or wrong answers.

Self-Assessment: Please identify your current skill level in the following areas using the following scale. 1= Skill in challenging. 2= Comfortable with the skill 3= One of my best skills

	1	2	3
Self-Discipline/Focus
Perseverance/Determination
Self-Confidence
Math Skills
Managing Stress
Writing Skills
Reading Skills
Study Skills
Time Management
Test-Taking Strategy

SSS Services: Please identify the most helpful services (check three to five services only).

Selecting a majorCareer PlanningFinancial ManagementScholarship SearchTransfer School PreparationFinancial Aid AdvisingCultural/Social ActivitiesUnderstanding Degree RequirementsCourse SelectionStudy Skills DevelopmentPersonal CounselingTutoringOther
Tutoring
Other
Please sign and date below after reading the following statement.

By signing the application, I agree that all the information on this application is true.
Student Signature

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
The Student Support Services Program is 100% federally funded.

The Student Support Services TRIO programs do not discriminate on the basis of race, color, national origin, sex, disability, or age in its program and activities.

SSS APPLICATION

Needs Assessment