Cameron University-SSS-Application Form

Cameron University Student Support Services (SSS) Membership Application
Legal Name:*

First NameMILast Name
Date of Birth:*

MonthDayYear
Date
Sex:*

MF
Social Security Number:*
999-99-9999
Student ID Number:*
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permanent Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
(999)999-9999
Home Phone:
(999)999-9999
Cameron E-mail:*
example@example.com
Do you own a Computer?*

YN
College Major/Minor selected:*
T-Shirt Size:*
Are you:*

SingleMarriedDivorcedWidowedSeperated
Ethnic Background:*

HispanicAmerican Indian/Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or Islander
Are you a:*

VeteranDisabled VeteranNeither
Do you believe you might be eligible for SSS by virtue of a disability?*

YesNo
If so, is your disability documented with the CU Disability Services Office?*

YesNo
Do you have a Family Educational Rights and Privacy Act (FERPA) Waiver on file with the University?*

YesNo
Has either of your parents graduated from a four year college?*

YesNo
Are you a:*

U.S. CitizenPermanent Resident
Registration #:*

Please indicate yes (Y), n (N), or sometimes (S) to the following statements:*

	Y	N	S
My overall GPA is 2.0 or higher
Test anxiety keeps me from getting the grades I want
I do not have a place to sleep or know when I will next eat
I'm quite confident regarding my college success
I am clear and focused on my career direction
I find it hard to either study or concentrate
Reading, understanding and remembering what I have read are fairly easy for me.
I am a full-time student
Math has been difficult for me
I am usually able to solve personal problems on my own
Friends and family actively support my educational goals
I manage my time effectively
I feel a need for more social or academic support in college
I have a lot responsibilities
High school was an enjoyable experience for me
I use the bus, Lyft, Uber, taxi, or depend on others for transportation
My physical health is good or excellent
I have a job
I have a positive attitude about myself and my ability to control and direct my life as I choose

What are your reasons for wanting to join Student Support Services?*
Which of the following obstacles will be the most difficult to overcome so you can complete your college degree?*

Poor study habitsBad gradesLack of moneyEmploymentUndecided majorHealth problemsTaking the wrong classesLife ChallengesLack of foodLack of consistent housingOther

Cameron University Student Support Services (SSS) Membership Application