Maysville Community & Technical College-SSS-Application Form

Maysville Community & Technical College

Student Support Services Participant Application
Student Support Services is a federal program funded through the U.S. Department of Education. Acceptance into the program is contingent upon meeting eligibility criteria and space availability. Please answer all questions completely. If a question does not apply to you, complete the question by marking "N/A". All information you supply will be held in strict confidence.
Name:*

First NameMiddle InitialLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Male or Female:

MaleFemale
Cell Phone #:
(999)999-9999
Alternate Phone:
(999)999-9999
School e-mail:*
example@example.com
Personal e-mail:
example@example.com
Student ID#:
Social Security #:
999-99-9999
Date of Birth:

MonthDayYear
mm-dd-yyyy
Are You a Veteran?

YesNo
Marital Status:

SingleMarriedSeparatedDivorcedWidowed
Place of Employment:
Hours Worked Per Week:
Emergency Contact Person:

First NameLast Name
Relationship:
Emergency Contact Phone #:
(999)999-9999
Primary Language:

EnglishSpanishOther
Citizenship:

American CitizenPermanent U.S. ResidentResident in U.S. with intention of becoming a U.S. CitizenPermanent resident of Trust Territory or Pacific Islands
Race/Ethnicity:

American Indian or Native AlaskanAsianBlack or African AmericanHispanic or LatinoWhiteNative Nawaiian or Pacific IslanderMore than one race
What is your total taxable household income?
$
Please select your yearly household income, before taxes:*

$0-$22,590$22,591-$30, 660$30, 661-$38,730$38,731-$46,800$46,801-$54,870$54,871-$62,940$62,941-$71,010$71,011-$79,080 (or more)
Number of People in Household:

123456More than 6
Disability Status (Mark all that apply):*

I have a documented disability.I have registered my disability with MCTC's Office of Disability Services.I am receiving services from Vocational Rehab.I do not have a documented disability
Did either of your parents graduate from a four-year institution of higher education?

NoYes
If yes, where?
What obstacle(s) would most likely prevent you from completing your academic goals? (Check all that apply):

Low self-esteemTest AnxietyLack of moneyToo ShyAlways worryingProblems at homeAlcohol and/or drug problemsTransportation problemsRecurring health concernsFamily Medical ProblemsTaking things too seriouslyEasily distractedPoor time management skillsHousing problemsDealing with bill collectorsNo support from family and/or friendsFeeling depressed or sadNo close friends at MCTCSeparation or divorceTrouble sleepingPoor Study HabitsTaking the wrong classesDisorganized notesPoor reading skillsPoor math skillsAfraid to speak up in class
Financial Aid:
Have you applied for financial aid at MCTC for the current school year?

YesNo
Have you been awarded financial aid for this semester?

YesNo
Did you receive a Pell Grant this school year?

YesNo
Do you have a declared academic major/minor?

YesNo
If yes, what is your major?
Minor?
Additional Information:
Which did you receive?

High School DiplomaGED
Have you ever been in foster care?

YesNo
Are you currently homeless?

YesNo
Records Release and Photo Consent:
By signing and/or submitting this document I authorize Maysville Community & Technical College to release to the Student Support Services program my student academic and financial records for the program director to use in a professional manner relating to my college educational experiences. These include but are not limited to:

Grade Transcripts

High School Transcripts

ACT & GED Scores

FAFSA Reports

Needs Analysis

Basic grant and awards letters
Initials:
I also authorize Maysville Community and Technical College to photograph or film me and consent for the use of my likeness in any and all publications, educational materials, research, advertising, news media, video, and World Wide Web materials; and I acknowledge the college's right to crop or treat the photograph at its discretion.
Initials:
I further understand and agree that these materials may be kept on file and/or used by MCTC for potential future uses and further agree to release the college from any and all liability arising from or in connection with the taking, use, publication, or dissemination of such materials.
Initials:
Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy

Participant Contract
I have discussed my academic and/or personal concerns with a member of the Student Support Services (SSS) staff. I understand that in order to receive services from this program, I am expected to:
- Maintain contact with my SSS counselor through telephone, e-mail, or face-to-face interaction at least three times each semester, or additionally as recommended by a SSS staff person.
- Contact a SSS staff member to reschedule cancelled and/or missed appointments.
- Participate in at least one cultural/enrichment and/or SSS workshop during each semester.
- Keep all appointments with my tutors, coming to each session fully prepared with the work assigned.
- Contact my tutor or a SSS counselor in advance if I need to cancel an appointment.
  If I fail to do so two times, tutoring services may be stopped per the discretion of the SSS Director under advisement from the Educational Specialist.
- Evaluate the SSS staff and services annually.
- Notify my SSS counselor when making any changes in my class schedule or dropping/withdrawing from any classes.
I understand that chronic failure to comply with the above may constitute grounds for my removal from the SSS program and all SSS services will be stopped until I renegotiate this contract.
Student Signature

Clear
Student ID #
Date:

MonthDayYear
mm-dd-yyyy