Western Kentucky University-Disabled-SSS-Application Form

Student Support Services, Disabilities
Thank you for your interest in participating in the Student Support Services, Disabilities program here at WKU. Our program is one of many student-oriented TRiO programs that provides support services to individuals who are often underrepresented in post-secondary educational settings.

Eligibility requirements for our program are as follows:

- Admitted to WKU as a degree-seeking undergraduate student

- United States citizen or permanent legal resident

- Has a documented disability and is registered with the SARC (refer to their website https://www.wku.edu/sarc for more information)

- Demonstrates academic need (low grades in high school/college, low admission test scores, nontraditional student, underrepresented minority, on academic probation, etc.)

In addition, SSS-D will give priority to applications of students that meet the following optional criteria:

- First-generation college student (neither parent has graduated with a degree from a four-year college or university)

- Limited income background (Pell eligible, determined by FAFSA information and annual low-income levels set forth by federal government)

If you’re not sure that you meet all of these criteria, feel free to fill out our application anyway! We will do our best to assist you and if our office is unable to provide the support you need, we can certainly connect you with other campus and community partners to help you in your journey toward academic success.

Contact Information
What is your WKU email address? (Please enter your personal email address if you have not yet received your WKU email address)*
example@example.com
What is your phone number?
(999)999-9999
What is your preferred contact method? (You may select more than one)*

Email (WKU)Email (personal)Phone (call)Phone (text)
What is your personal email address?
example@example.com
What is your permanent address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your local/on-campus address the same as your permanent mailing address?*

YesNo
What is your local/on-campus address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Academic Information
What is your WKU ID#? (800... or 801...)*
What is your anticipated/declared major?
What is your year/classification?

Freshman/First yearSophomore/Second yearJunior/Third yearSenior/Fourth+ year
Are you a transfer student?

YesNo
Have you participated in another TRiO program before? (SSS, Upward Bound, Educational Talent Search, etc.)

YesI'm not sureNo
How did you hear about the Student Support Services, Disabilities (SSS-D) office?

Agreements and Signature
Are you a member of the WKU Kelly Autism Program, Circle of Support program?

YesNoUnsure
Is there anything else you think we should know? (Questions, comments, concerns, etc.)
I hereby authorize my participation (including but not limited to photos, interviews, and testimonials) in program marketing efforts.

I give permission for Student Support Services, Disabilities project personnel to access my WKU academic and financial aid records for the purposes of verifying initial program eligibility and providing services throughout the year.
RELEASE OF RECORDS: The "Release of Records" is required for program participation. Records will be used to assess student needs, monitor progress, document eligibility, and for reporting purposes. This information is confidential and protected under the General Education Provision Act. SSS-D will not release any confidential information without your written consent.

I hereby grant permission for the Student Support Services, Disabilities program at Western Kentucky University to have access to educational records, including (but not limited to) grades, test scores, financial aid eligibility, class schedules, and attendance for the duration of the student's enrollment in the WKU Student Support Services, Disabilities Program. This also authorizes the postsecondary institutions to release to the WKU Student Support Services, Disabilities program copies of college academic enrollment and student aid award information.
I authorize the use of my photo by SSS-D for publicity and recruitment purposes for the duration of the student's involvement in the SSS-D program.

If you do NOT authorize SSS-D to use your photo for media purposes, please check this box
I understand that checking “I Accept” and typing my full name in the box below constitutes an electronic signature.

I acceptI decline
Please type your full name in the box below. (You will be asked to sign, in person, at a later date)

Student Support Services, Disabilities