Fayetteville State University-STEM-SSS-Application Form

TRIO STUDENT SUPPORT SERVICES

STEM & HEALTH SCIENCES

NEEDS ASSESSMENT

NEEDS ASSESSMENT*

	Yes	No
1. I need to get better grades in college.
2. I need to develop stronger study skills and habits.
3. I need tutoring
4. I need to learn how to set goals and make better decisions.
5. I need to understand how the courses I am taking relates to my career plans.
6. I need to better understand my interests, abilities and other traits.
7. I need to learn about the correct academic classes that I should be taking to complete my degree.
8. I am interested in a STEM career after graduation and need all of the help that I can get with achieving.
9. I need assistance with financial aid and researching scholarships.
10. I need to get involved in positive activities, extra-curricular activities and/or clubs or organizations.
11. I am considering dropping out of college.
12. I am a new transfer student at FSU this school year?
13. I have been out of school for an extended amount of time.
14. I am currently sharing housing due to economic hardship or loss of housing, awaiting Foster Care placement, living in a Foster home, residing in a Group home or an emergency/transitional shelter.

If tutoring, which subject(s)?

ScienceMathEnglishHistoryOther
I have participated in the following (check all that apply):

Upward Bound Math & ScienceUpward BoundGEAR UPTalent SearchRonald McNairEducational Opportunity CentersEarly CollegeStudent Support ServicesOther FSU STEM Program
Other FSU STEM Program Name:

ELIGIBILITY INFORMATION
ELIGIBLITY INFORMATION
Do you have an Associates Degree?*

YesNo
If yes, then list:
Prior to reaching 18 years of age, were you an emancipated minor or did you have a court-appointed legal guardian?*

YesNo
If yes, then list:
Are you registered with the Students with Disabilities Services Office?*

YesNo
If yes, please upload a copy of your Letter of Accommodations.

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FIRST-GENERATION
FIRST-GENERATION
A first-generation college student is defined as a (1) A student neither of whose natural or adoptive parents received a bachelor's degree (4-year college degree); (2) A student who, prior to the age of 18, regularly resided with and received support from only one parent and whose supporting parent did not receive a bachelor's degree (4-year college degree); or (3) An individual who, prior to the age of 18, did not regularly reside with or receive support from a natural or an adoptive parent. Based on this definition, are you a first-generation college student?*

YESNO

INCOME VERIFICATION
INCOME VERIFICATION
Income Verification Please complete only 1 of the 3 sections below. Check the appropriate box to indicate your chosen method of income verification. If you are an independent student, please use your own income information. If you are a dependent student, please use your parent/guardian’s income information

Option 1: Income Tax Return Included: I am including my/my parent or guardian’s income tax return for last year with this application.Option 2: Financial Aid Application Included: I am including my Student Aid Report or most recent Free Application for Federal Student Aid.Option 3: Statement including Family Taxable Income and Family Size:
Parent or guardian's income tax return

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Student Aid Report or most recent Free Application for Federal Student Aid

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Statement including Family Taxable Income and Family Size:
Select one:*

IF UNDER 24 YEARS OF AGE, SINGLE, NO CHILDREN OR CHILDREN RECEIVING LESS THAN, PROVIDE YOUR PARENT'S TAXABLE ANNUAL INCOME ON THE MOST RECENT TAX RETURNIF OVER 24 YEARS OF AGE, MARRIED, A VETERAN OR ACTIVE MILITARY, HAVE CHILDREN WHO RECEIVE MORE THAN HALF OF THEIR SUPPORT FROM YOU, OR AN ORPHAN OR WARD OF THE COURT, PROVIDE YOUR TAXABLE ANNUAL INCOME ON THE MOST RECENT TAX RETURN
I/my parent or guardian filed an income tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is ___________.*
I/my parent or guardian's taxable income for the last year was $__________ (Form 1040 Line 11b). Please note that taxable income is different from gross or net income.*
●DO NOT USE YOUR ADJUSTED GROSS INCOME●
Do you receive any of the following:*

Pell GrantWorkstudyScholarshipStudent Loans

PERSONAL STATEMENT
PERSONAL STATEMENT
Please write a short statement about your educational goals and career aspirations. In your statement please tell what you would like to do with your STEM degree and what support you may need in order to graduate.*
By signing below, you attest that all of the information is accurate and true. You also authorize TRIO Student Support Services STEM & Health Sciences to retrieve all relevant information to verify eligibility for participation, including social security number, as well as admissions, academic, and financial data from the Office of Admissions, the University Registrar, the Office of Financial Aid, the Division of Academic Affairs, Student Business Services, and the Office of Institutional Reesearch.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature (for dependent students under the age of 24)

Clear
Date

MonthDayYear
mm-dd-yyyy

TRIO STUDENT SUPPORT SERVICES