Coastal Alabama Community College-Monroeville-SSS-ApplicationForm

SSS APPLICATION
Date*

MonthDayYear
mm-dd-yyyy
Student #*
Name*

First NameMILast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check the campus that you will be attending*

MonroevilleThomasvilleOnline
Cell Number*
(999)999-9999
Home 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 Hawaiian/Pacific Islander
Ethnicity*

WhiteBlack/African AmericanAsianHispanicAmerican Indian/Alaskan NativeNative Hawaiian/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 graduating from Coastal Alabama Community College?*

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
Total Number in Family
Most recent taxable income
Financial Aid (check the boxes you are receiving)

Work-studyPell GrantAthletic ScholarshipPerforming Arts ScholarshipAcademic ScholarshipOther

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.

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
Student Support Services

Participant Contract

I understand that if I fail to live up to my obligations as a member of this program that my actions will be considered justification for being dropped from the program and place filled by another student whose name is on the waiting list.
1. To provide the project director and/or specialist with a copy of transcripts, financial aid SAR form, and financial aid award letter.
2. To permit the project director and specialist to have access to academic and financial aid records.
3. To complete the Placement Test or ACT, Myers-Briggs Personality Inventory, Career Assessment, and personal budget.
4. To attend all meetings, tutorial sessions, seminars, workshops, and educational trips promptly and well prepared. I understand that I am to attend all activities unless I receive an exemption from my project specialist. In order to receive an exemption, I must demonstrate that I do not need a particular service.
  1. Tutoring is required in any course in which there is a documented need for assistance. If three tutorial sessions are missed with unexcused absences, the tutoring will no longer be available to me during that particular semester.
  2. Financial Aid Workshop is required.
  3. Career Workshop is required.
  4. Money Management Seminar is required.
  5. Regular class attendance is required.
5. To consent to be monitored in all classes of the purpose of receiving tutorial assistance and academic advisement. I understand that SSS will follow my academic progress through graduation from a two-year to a four-year institution.
6. To meet with the project specialist at least twice each semester to discuss problems, successes, concerns, etc. I will let the SSS staff know when more assistance is needed.
7. To maintain the following GPA to remain active in SSS: 2.0
8. To meet with the project specialist if I am placed on academic warning to discuss ways to improve my academic standing.
9. To consult with the specialist before withdrawing from any classes or before withdrawing completely from CACC.
10. To complete an exit interview with Project Specialist before transferring, graduating, or withdrawing from CACC completely.
11. To honestly evaluate all program staff, services and tutors each semester on the forms/surveys provided.
Signature

Clear
Student Support Services

Student Interview
Briefly explain why you want to join Student Support Services.
Briefly explain your major, where you plan to transfer (if applicable)
Student Support Services offers participants seminars, cultural enrichment activities, and transfer trips for four-year colleges/universities. Would you be willing to give up your free time to participate in these free activities?

YesNo
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.