University Of Arkansas-Phillips Community-SSS-Application Form

What Campus are most of your classes located on?*

Please complete this form and return it to the Student Support Services office.

Name*

First NameMILast Name

Preferred Name:*

Student ID#:*

Date of Birth:*

Date

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell #*

(999)999-9999

E-mail*

example@example.com

U.S. Citizen*

YesNo

Permanent Resident Alien Registration #*

Ethnicity: Are you Hispanic/Latino? (If yes, also choose a race below.)*

YesNo

Race*

Gender:*

MaleFemale

Marital Status:*

SingleMarried

Do you need academic adjustments because of disabilities?*

YesNoNot Sure

Have you applied for or are receiving any student financial aid?*

YesNo

Does your mother/guardian have 4-year college degree (Bachelor's)?*

YesNo

Does your father/guardian have 4-year college degree (Bachelor's)?*

YesNo

Check highest education level that you have completed.

High School GraduateGED GraduateCollege Graduate, Associate's DegreeCollege Graduate, Bachelor's Degree or Higher

School name:

Date graduated:

mm/yr

Date Graduated:

mm/yr

What degree or certificate are you pursuing? (Please check one below.)

What is your college major?

Please check if undecided?

Undecided

Have you attended any other college or university?

YesNo

If yes, provide school name

and dates attended

mm/yr to mm/yr

How many hours are you enrolled in this semester?

Do you plan to transfer to a 4-year college after graduation?

YesNo

If yes, which 4-year college(s) are you considering?

Please check if undecided?

Undecided

What is your college classification?

Freshman (0-29 hours)Sophomore (30-60+ hours)

Check all that apply

Did you have low High School Grades? (1)Did you have low admission test scores? (2)Did you attain your GED? (8)Do you have low college grades? (7)Do you have failing grades? (9)Are you a returning student who hasn't been in enrolled in 5 or more years? (10)Do you have Educational and/or Career goals? (13)Are you academically prepared for college-level coursework? (14)Do you need academic support to raise your grades? (15)

Study Skills Support

Financial Aid/Financial Literacy

Academic

Transfer Assistance

Career Planning

Personal Assistance

Please carefully read and agree to each of the following statements by checking yes or no.

Have you participated in any other TRIO Programs?

YesNo

Agree to attend class regularly and sign in to my online classes regularly.

YesNo

See your SSS mentor at least once per month during the fall and spring semeesters and upon request by an agreed-upon method (phone, in-person, text, email.)

YesNo

Participate in SSS activities and workshops virtually or in person.

YesNo

Inform your SSS mentor of any difficulties you might be having that have the potential to impact your academic goals negatively.

YesNo

Be actively involved in your education.

YesNo

I certify that the information given above is true and correct to the best of my knowledge. I understand the Student Support Services (SSS) Program at PCCUA will review my PCCUA academic and financial aid information. Due to Federal reporting requirements, I understand that SSS will follow up on my post-secondary education and provide information to the U.S. Department of Education. Also, SSS may use my name, photo, or information about me in all college media sources.

Signature

Date

mm-dd-yyyy

Note: The information you provided is kept strictly CONFIDENTIAL. The information requested on this form is used strictly to determine program eligibility and provide program demographic information to the U.S. Department of Education.

Application for Services

Personal Data

Eligibility

Academic Data:

Please check below the area(s) with which you would like assistance: