Broward College-Disabled-SSS-Application Form

BROWARD COLLEGE

STUDENT SUPPORT SERVICES INFORMATION SHEET FOR STUDENT’S WITH DISABILITIES

Student Support Services- Student’s with Discibilities (SWD) is a learning community that offers members free comprehensive academic support services to enhance their performance and promote academic success. Our goal is to retain and graduate students who are first generation, low‐income and/or have a disability. SSS is a grant funded program through the U.S. Department of Education.

Eligibility is based on federally defined criteria where at least one of the following must be met:
- Have a documented learning or physical disability
An eligible student must need academic support and be either a US citizen or permanent resident who has not yet earned a bachelor’s degree but is committed to using SSS resources and graduating from Broward College.

How can SSS help?

Advising:
- Course Selection
- Registration Assistance
- Choosing Majors and Careers
- Developing an Individual Graduation Plan
- Baccalaureate Transfer Planning
Financial Assistance:
- FAFSA Forms
- Scholarship Applications
- Grant‐Aid and Scholarships
- Financial Planning
- Economic Literacy Workshops
Instruction:
- Workshops and Classes
- Tutoring
- Writing, Math and Reading/Study Skills Assistance
Resources:
- Resource room with Computers and Printer
- Resources
WHEN SHOULD I APPLY?

Immediately! Applications are accepted throughout the year, but program size is limited. Please answer all the questions on the application, print clearly in ink. Your responses are necessary to determine program eligibility and will be kept confidential.

If you have questions or need assistance with the application, please email SSS@broward.edu

“The mission of TRIO Student Support Services is to provide unique and personalized academic support services in an environment that inspires engaged learning.”

Personal Information
Student ID No.
Name*

First NameLast Name
Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Numbers
Residence
(999)999-9999
Cell
(999)999-9999
Work
(999)999-9999
Email Address*
example@example.com
Best time to contact you
Permanent Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
mm-dd-yyyy
Gender

MaleFemale
Marital Status
No. of children under 18
Are you a U.S. Citizen?

YesNo
Permanent Resident?

YesNo
Res. #: A
Ethnic Background

American Indian/Alaskan NativeAsian-Pacific IslanderAfrican-AmericanCaucasian/WhiteHispanicMultiracial (more than one race)
What is your first language?

Program Eligibility
Do you have a documented disability for which you are requesting services?

YesNo
Have you participated in a TRIO program in the past?

YesNo
If yes, check all that apply

Upward BoundEducational Talent SearchEducational Opportunity CenterOther

Educational History
Is this your first college experience?

YesNo
Current Class Standing

First Year (never attended college before BC-Freshman)First Year (some college credit from another school-Freshman)Second Year (at least 30 credits-Sophomores)
Veteran

YesNo

Affidavit of Truth Statement
I hereby certify that the information provided is true to the best of my knowledge.

I hereby authorize the release of my records in reference to academic transcripts, degree plans, personal assessment scores, financial aid, and any other pertinent information related to my academic endeavors to the Student Support Services staff of Broward College.
We like to recognize student achievements. Do you grant permission to include your name or picture for program related publicity, exhibits or displays? Please indicate preference:

Permission to print namePermission to print photoNeither name nor photo
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear

Submit
Please verify that you are human*
Should be Empty: