Weber State University-STEM-SSS

APPLICATION TO THE STUDENT SUPPORT SERVICES STEM PROGRAM
WEBER STATE UNIVERSITY

Student Support Services STEM
Weber State University
Student Services Center Room 160
Email Address: sss-stem@weber.edu
- Date
  
  MonthDayYear
  mm-dd-yyyy
- W#
- Name
  
  FirstMILast
- Address
  
  Street
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Cell
  (999)999-9999
- Home
  (999)999-9999
- Email Address
  example@mail.weber.edu
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Gender
- Citizenship
- Permanent Resident Card
  
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- What is your race and/or ethnicity? (check all that apply)
- Current Enrollment Status
- Expected Degree - Major
- Expected Degree - Minor
- Educational Goals
- Services you are interested in
- Have you been in SSS or another TRiO program previously?
- If yes, what was the name of the program?
- How did you hear about the Weber State SSS-STEM program?
- Do you have a leave of absence planned within the next 5 years? (ex: military, LDS mission, baby's birth)
- Entrance date to Weber State University - Semester
- Entrance date to Weber State University - Year
- What is the highest level of your parents' or guardians' education?
- Parent/Guardian 1 Name
  
  First NameMiddle NameLast Name
- Highest Level of Education (Parent/Guardian 1)
- Parent/Guardian 2 Name
  
  First NameMiddle NameLast Name
- Highest Level of Education (Parent/Guardian 2)
- Applications without required tax documentation or financial status statements will NOT be considered
- Have you filed federal taxes in the past two years?
- If yes, please attach a copy of your most recent 1040 U.S. Individual Income Tax Return.
  
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- Did someone (such as a parent or guardian) claim you as a dependent on their taxes for the most recent tax year?*
- If yes, please attach a copy of your parent or guardian's most recent 1040 U.S. Individual Income Tax Return form.
  
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- Please check if either applies to you
- *a dependent student is a student that is under 24 years of age, unmarried, has no dependents of their own, is not serving on active duty in the U.S. armed forces, is not a veteran of the U.S. armed forces, has not been an orphan or in foster care since they turned 13, and were never a legally emancipated minor
- Financial Status Explanation
  
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- (Note: If your tax information does not accurately reflect your current financial situation, please attach a signed statement that explains the change to your income level.)
- Signed Statement
  
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- Documented Disabilities
- Are you registered with Weber State Disability Services?
- If yes, please attach a letter from Disability Services.
  
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- How many hours per week do you plan to work during the semester
- High School Attended
- Year Graduated
- Approximate High School GPA
- Rate your confidence in math on a scale of 1 to 5 (1 meaning no confidence and 5 meaning extremely confident).
- Rate your confidence in verbal communication skills on a scale of 1 to 5.
- Rate your confidence in your study skills on a scale of 1 to 5.
- Rate your sense of financial security on a scale of 1 to 5 (1 meaning very low security and 5 meaning very high).
- Rate your determination to obtain a degree on a scale of 1 to 5 (1 meaning not very determined and 5 meaning extremely determined).
- On a scale of 1 to 5, how prepared do you feel for college?
- Is English your native language?
- Authorization of Information/Statement of Authenticity
  
  I authorize Weber State University or other universities I attended or am attending to release official transcripts, test scores, financial aid award information and other records to the Weber State University Student Support Services STEM program for educational planning purposes. I also authorize the above stated program to release these records to other institutions as they relate to my education planning.
  
  I attest that the information I have provided is true and correct to the best of my knowledge. I attest that the documents I have presented for verification of eligibility are genuine and relate to me. I am aware that any false documents in connection with eligibility will be cause for my dismissal from the Student Support Services STEM program.
- Student Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Name
  
  First NameMiddle NameLast Name
- Parent/Guardian Signature (if student is under 18)
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Confidentiality of Information
  
  The personal information that is provided to the Student Support Services STEM program will be protected under the Family Educational Rights and Privacy Act of 1974. No one will have access to the information unless they work with or for the Student Support Services STEM program or are specifically authorized by the student in question to see the information. The information is necessary to help determine the success of participants in post-secondary education as authorized by the U.S. Department of Education
  
  (20 United States code 1231a)
  
  PLEASE NOTE:
  
  The application must be completely filled out with required documents attached (tax documentation or financial status statement, and documentation from Disability Services if applicable). Permanent residents must attach a copy of their resident card.
  
  Incomplete applications will not be accepted.