Seminole State College-SSS-Application Form

SEMINOLE STATE COLLEGE STEM Student Support Services Application
Name*

First NameMiddle InitialLast Name
DOB*

MonthDayYear
mm-dd-yyyy
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell:*
(999)999-9999
E-mail:*
example@student.sscok.edu
Student ID:*
US CITIZEN:*

YesNo
If not, are you a Permanent Resident?*

YesNo
Do you identify as Hispanic or Latinx?

YesNo
ETHNICITY:*

AsianWhiteBlack/African AmericanNative Hawaiian / Pacific IslanderAmerican Indian / Alaskan Native
GENDER:*

FemaleMaleTransNon-binaryGender queerGender Non-conformingPrefer not to sayOther
What are your pronouns
Eligibility
1. Did either of your parent(s) or legal guardian(s) graduate with a bachelor’s degree?*

YesNo
2. If yes, was it before you turned 18 years of age?*

YesNo
3. Did you live with this person until you turned 18 years of age?*

YesNo
4. Have you completed the FAFSA?*

YesNo
5. Are you currently receiving financial aid?*

YesNo
6. Financial Aid Dependency Status: Please select all that apply.*

Both parents are deceasedHave dependent Children24 years of age or olderArmed Services VeteranWard of the CourtMarriedNone
*If you selected “NONE” you are considered a DEPENDENT Student and must submit one of the following for your application to be complete: (1) a signed SSS Income Form from your parent or legal guardian, (2) a signed copy of your parent or legal guardian’s 2022 tax form with TAXABLE Income, or (3) a signed Federal Aid Report with parent or legal guardian’s income, size of family unit, and dependency status.

** If you checked at least ONE of the options above, you are considered INDEPENDENT and can submit your own income information. Please complete the next two questions:
INDEPENDENT Student’s 2022 TAXABLE Income*
INDEPENDENT Student’s # in family unit*
7. Have you obtained a college degree?*

YesNo
8. Do you have a disability, either physical or learning, that is documented through the SSC Accessibility Services Office?*

YesNo
9. Which SSC Degree/Certificate are you pursuing?*
DEPENDENT Student: Please submit the Income Verification Form signed by your parent or legal guardian or submit a copy of your 2020 tax form with TAXABLE Income.
PRIVACY ACT: In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services Program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services Program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing the information on this form, including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties.

I am aware that there are TWO Student Support Services programs on campus (SSS Traditional and STEM SSS.) I understand that, although I can apply to both programs, I am only permitted to be served by one program. Once accepted into a program, I acknowledge that I should receive services from that program. I cannot be a participant in both programs.
Initial*
10. Please check all the ways you have need and believe we can assist you:

Completing the FAFSAPlanning my ClassesPlanning for TransferAcademic Support SystemFinancial LiteracyStudy/Learning SkillsNavigating CollegeChoosing a MajorBecoming involved in collegeA quiet place to studyChoosing a CareerMeeting new peopleTest TakingTime ManagementComputer Lab/PrintingSetting and achieving goalsPeer MentoringDecision-MakingAcademic WorkshopsTutoring
11. Tutoring: Please list all classes:
12. Please check all of the following that interest you or would be beneficial to you:

Tours of university campusesAdvisement that helps you plan for graduationCultural eventsVirtual Job Shadow Online ProgramFoundations of Financial Literacy Online ProgramLearning Styles Online ProgramGrant AidLeadership opportunitiesScholarship Application AssistanceTutoring
13. Please check any of the following that describe you:

I have limited knowledge about collegeI do not have much support from family/friendsI do now know anyone else attending SSCI do not know my preferred learning styleI work over 20 hours per weekI have been out of school for five years or moreI fear that I will not succeed in collegeI do not know people with knowledge about collegeI need to ask questions but am afraid or do not know who to askI have struggled to learn material or enjoy school in the past
14. How did you hear about the program?
Have you previously participated in:

Student Support ServicesUpward BoundFOCUSNASNTIGEAR UP
When?
Where?
Application Acknowledgement and Release of Information Agreement: I certify that the information I have provided on this application is, to the best of my knowledge, true and correct. Further, I authorize the Student Support Services Program/professional personnel to receive and/or release my records including, but not limited to, transcripts, financial aid documentation (ie. FAFSA, ISIR, SAP, default information, scholarships, unmet need) academic plans, class schedules, probationary/suspension information, test scores, and other academic records/materials pertinent to my participation, including postsecondary information from the National Student Clearinghouse. I understand that my records are protected under State and Federal Confidentiality regulations. These records will be used internally for evaluating the need for program services, setting academic goals and measuring progress toward meeting goals. This information is required by law to meet U.S. Department of Education (the federal government grant funding agency**) regulations for the Student Support Services Program. Although this release may be revoked upon my written request, I agree that it shall be valid throughout my participation in the Student Support Services Program and beyond for verification of postsecondary enrollment, academic progress, graduation, and transfer.

I am aware that there are TWO Student Support Services programs on campus (SSS Traditional and STEM SSS.) I understand that, although I can apply to both programs, I am only permitted to be served by one program. Once accepted into a program, I acknowledge that I should receive services from that program. I cannot be a participant in both programs.
Signature of Student*

Clear
Date of Signature*

MonthDayYear
mm-dd-yyyy
**SSS / STEM SSS is a federally funded program by the U.S. Department of Education hosted by Seminole State College. Seminole State College is an equal opportunity educator and employer. Updated 06/15/2022

SEMINOLE STATE COLLEGE STEM Student Support Services Application