Corporation Of Mercer University-Henry County-SSS-Application Form

The Office of Nontraditional and Evening Services (The ONES)
A TRIO Student Support Services Program

Section 1: Contact Information
Name*

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
(999)999-9999
Cell Phone Number
(999)999-9999
Check this box if you consent to receiving text messages from ONES for important updates

I consent to receiving text messages from ONES for important updates
Personal E-mail Address*
example@example.com
Mercer E-mail Address
example@example.com
Check the preferred contact e-mail

Personal E-mailMercer E-mail

Self-Assessment of Academic Needs

	Yes	No
I have been out of school for five or more years
I have low college grades or GPA
I have failed a course(s) while in college
I am undecided about my future career
I am confused about the classes needed for graduation
I have limited English Proficiency
I find writing challenging
I find math challenging
I find reading textbooks challenging
I am undecided about my major
Other (specify below)

Release of Records and Information Agreement
I affirm that all of the information provided is true and accurate to the best of my knowledge. I understand that I will be provided with services that will help me plan and complete my educational goals. In addition, I authorized the Center of Nontraditional and Evening Services (TRiO SSS Program) to request, obtain and release financial aid, academic, enrollment and/or disabilities records at Mercer University in order to provide services and generate reports. I also give permission for the use of my name and/or photograph for editorial, promotional, recruitment and educational purposes.

TO ELECTRONICALLY SIGN: Please click in the signature area with your mouse and drag to draw your signature.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Academic Success and Achievement Plan
1. Personal concerns about returning to school?
2. Any academic issues that seem to be your biggest concern?
3. Academic History: Did you attend another school prior to Mercer? If so, why did you choose to continue your education at Mercer University?
4. Career Assessment: What is your ultimate career goal, and what issues (if any) do you think you might need help with achieving your career goal? (i.e., interview skills, resume writing, locating an internship)
5. Financial Profile: Do you have any financial concerns regarding college?
Any other comments/concerns?