Midwestern State University-SSS-Application Form

Student Support Services – Application

2024-2025 Cohort
To determine eligibility, please complete this form. The information you provide is strictly confidential. Because this is a federally funded program, this information is required for students who wish to participate in the Student Support Services program.
Name*

First NameMiddle InitialLast Name
Preferred Pronouns
Mustang ID Number*
Date of Birth*

MonthDayYear
mm-dd-yyyy
Local Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
Do we have permission to text you?*

YesNo
E-Mail*
example@example.com
Name of Primary Parent/Legal Guardian*

First NameLast Name
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
(999)999-9999
E-Mail*
example@example.com
Academic Information
Entry Date to MSU*

MonthDayYear
mm-dd-yyyy
Expected Date of Graduation*

MonthDayYear
mm-dd-yyyy
Classification*

Freshmen (0-29 hours)Sophomore (30-59 hours)Junior (60-89 hours)Senior (90+ hours)
Enrollment Status*

Full-timePart-timeLess-than-Part-time
Major(s)*
Minor(s)*
Cumulative GPA*
On a 4.0 scale
Are you a transfer student?*

YesNo
If yes, from where?
Entry Date to College (if elsewhere)

MonthDayYear
mm-dd-yyyy
Did you pass all portions of the TSI test?*

YesNo
If not, which TSI sections did you not pass? Mark all that apply.

MathReadingWriting
Have/Were you required to enroll in Remedial Coursework?*

YesNo
Are you currently on academic probation?*

YesNo
Financial Aid/Income Information
Have you completed the FAFSA for the 2024-2025 Year?*

YesNo
Does someone claim you as a dependent on their tax return?*

YesNo
Please remember to provide a copy of both your primary parent/legal guardians’ and/or your own most recent IRS 1040 Income Tax Forms. If you did not file, plan to file, or have any questions please contact Student Support Services at (940) 397-4135 or SSS@msutexas.edu.*

I acknowledge this statement
Do you have children you provide care for ≥ 50% of the time?*

YesNo
Number of members in the household (including yourself):*
(please provide a numerical value)
What type of financial aid are you receiving?*

Pell GrantWork StudyScholarshipLoanNoneOther
Previous Grant-Program Participation
If you previously participated in another TRIO / other federally-funded program, please check which one(s):

Educational Talent SearchUpward BoundUpward Bound Math/ScienceStudent Support ServicesOther
Demographic Information
Ethnic Identity- Please check the identity that describes you best.*

American Indian / Alaskan NativeHispanic or LatinoAsian / American AsianBlack / African AmericanNative Hawaiian / Pacific IslanderMiddle EasternCaucasianNo Response/Unknown
At any time since you turned 13, were both your parents deceased, were you in foster care, or were you a dependent or ward of the court?*

YesNo
Are You a U.S. Citizen?*

YesNo
If you are an eligible non-citizen, provide your A Number:
Gender*

MaleFemale
Parent’(s)/Legal Guardian’(s) Highest Level of Education
Father’s Education:*
Mother's Education:*
Disability Verification
Do you have a documented disability?*

YesNo
Have you been diagnosed as having a learning disability?*

YesNo
Have you been diagnosed with a physical disability?*

YesNo
Are you registered or do you plan to register with MSU’s Disability Support Services?*

YesNo
Are you currently receiving services from The Department of Assistive and Rehabilitative Services (DARS)?*

YesNo
Academic and Needs Assessment

Please check which services you would like to receive from SSS
Counseling*

Monitoring academic progressOne-on-one academic counseling with SSS staffStudent Support Services MentorAssistance with scholarship search and applicationsGraduate School ToursSSS Mixers / Events
Tutoring*

ReadingMathWritingAssistance with other coursework
How else can we help?
Educational Motivation

Please Check true or false for the following questions*

	True	False
I have set a goal to do well in college
Good grades are a matter of luck and timing
I spend two hours studying for every hour I am in class
It must be quiet when I study
I know to how to take notes in class
I study at home
When a subject is difficult for me, I study the easy parts
I finish assignments on time
I read over my course materials before class
I frequently wonder if school is really worthwhile for me
It is up to my professors whether or not I will learn in class
I understand and accept the responsibility of doing well in college

Please Check true or false for the following questions*

	True	False
I have set a goal to do well in college
Good grades are a matter of luck and timing
I spend two hours studying for every hour I am in class
It must be quiet when I study
I know how to take notes in class
I study at home
When a subject is difficult for me, I study the easy parts
I finish assignments on time
I read over my course materials before class
I frequently wonder if school is really worthwhile for me
It is up to my professors whether or not I will learn in class
I understand and accept the responsibility of doing well in college

Mark the box next to the statements that apply to you*

I have trouble reading college-level textbooksI have trouble taking notes from lecturesI would like to improve my grammar and vocabularyI am uncomfortable asking questions in classI learn best by actually doing somethingI learn best by listening to explanationsI learn best by watching something being doneI am able to conduct research and organize a paperI have difficulty writing papersI know when it is time to get help in a classI am uncomfortable asking for tutoringI seek academic support with my classesI understand what I readI have test anxietyI use a planner/calendar to keep track of my courseworkI read my syllabus for each classI have difficulty concentratingI have difficulty speaking, reading, or writing in English
CONTRACT
I understand that I will have access to the Midwestern State University Student Support Services (SSS) staff members and will have use of the SSS facility and all available services. I am aware that I am required to update my Academic and Career Evaluation Plan each academic semester to ensure my file remains current and to determine the nature of the services I need.

I understand that I will meet with a staff member once a month during each academic semester, and I will obtain tutoring should my grade(s) fall below a C average. If I am on academic probation, I agree to have contact with SSS at least two times a month in order to develop a plan to improve my academic standing.

I hereby give permission for SSS staff to disclose and receive information concerning the nature of my SSS eligibility and information concerning my academic progress on an as-needed basis with appropriate faculty and staff at MSU Texas. I also give SSS staff permission to view and receive any and all financial aid information from the Financial Aid Office.

My signature verifies that I have read and understood this contract, and that the information I have provided on this application is true and accurate to the best of my knowledge.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Student Support Services – Application

Academic Information

Financial Aid/Income Information

Previous Grant-Program Participation

Demographic Information

Parent’(s)/Legal Guardian’(s) Highest Level of Education

Disability Verification

Academic and Needs Assessment

CONTRACT