Emporia State University-SSS-Application Form

Full Legal Name (include middle initial if you have one):

First NameMiddle InitialLast Name

Preferred First Name

Social Security No.

999-99-9999

ESU Student ID:

Campus Address: (Where you live while at ESU - Residence Hall & Room, local address, or “same as Perm. Address”). If you don’t know your campus address yet, just write “Campus” for now and we will look it up or get it later.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

College Address (Where you live while at ESU - Residence Hall & Room, local address, or “same as Perm. Address”)

If you don’t know your campus address yet, just write “Campus” for now and we will look it up or get it later.

Cell Phone:

(999)999-9999

Other Phone:

(999)999-9999

Perm Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Campus Email:

example@example.com

Personal Email:

example@example.com

Date of Birth:

mm-dd-yyyy

Sex:

Ethnicity: Are you Hispanic/Latino/a origin?

Race (Check any and all that apply – MUST CHECK AT LEAST ONE):

Date you first enrolled or attended Hornet Connection at ESU?

mm-dd-yyyy

Are you a U.S. Citizen?

If No, are you a permanent resident?

What is your academic standing?

Have you participated in other Educational Opportunity Programs (i.e., AVID, GEAR UP, Talent Search, Upward Bound)?

If yes, name?

Have you declared a major:

If you have, what is it?

If you are a transfer student, what school have you transferred from:

How many hours are you transferring to ESU (if you know)?

Do you plan to complete your degree at ESU?

1. Did either parent or legal guardian(s) with whom you regularly reside receive a 4-year college degree before you turned 18?

2. Will you be or are you currently receiving financial aid through the ESU Financial Aid Office?

If NO, why?

3. Do you have a learning, psychological, or physical disability?

If Yes, will you or have you filed for services with ESU’s Student Accessibility and Support Services (SASS) Office?

4. Did you have an IEP or a 504 Plan in school?

As a federally funded program, TRIO Student Support Services (SSS) is required to provide documentation of students’ program eligibility. One important aspect of eligibility is verification of “Family Income.” Verification requirements vary depending on whether students are independent or dependent. (A list of criteria for independent student status is available at www.fafsa.ed.gov.)

Number of people supported by the family unit (please include yourself):

Are you a dependent student? (A dependent student means you are younger than 24; unmarried/not emancipated; parental income is reported on your FAFSA. You are considered a dependent student even if your parents are not helping you pay for college expenses if you meet the above criteria.)

Are you a dependent or independent student? (A dependent student means you are younger than 24; unmarried/not emancipated; parental income is reported on your FAFSA. You are considered a dependent student even if your parents are not helping you pay for college expenses if you meet the above criteria).

Did parent(s)/guardian(s) file a tax return last year?

If not, enter last year’s total income:

Parent/guardian’s TAXABLE income (not adjusted gross income) for the previous year from the tax return:

(or attach a copy of tax return for the previous year)

Parent/Guardian Signature

Date

mm-dd-yyyy

Are you an independent student? (Typically, 24 or older; a parent or married/emancipated; military veteran; parental income is not reported on your FAFSA.)

If independent, did you file a tax return last year?

If not, enter last year’s total income:

Student’s TAXABLE income (not adjusted gross income) for the previous year from your tax return:

(or attach a copy of your tax return for the previous year)

Statement of Certification

To the best of my knowledge, all information provided on this application is true and complete.

Statement of Agreement and Consent

I understand that the SSS program will use the data provided on this form to assist in determining eligibility and all information will be kept confidential.

I authorize Emporia State University Student Support Services to gather my high school and college transcripts, placement scores, FAFSA and scholarship information, disability documentation, ACT scores, and other necessary information in order to provide the services I have requested, and to make reports to the U.S. Department of Education for the re-funding of this program. I also authorize SSS to obtain periodic reports from my instructors regarding my academic progress for courses in which I am enrolled, as well as obtain college enrollment and degree information from National Student Clearinghouse. I understand that all information will be kept confidential and will be used for the following specified purposes:

a. student demographic data and record keeping
b. program evaluation
c. needs assessment
d. federal reporting
e. other administrative purposes

I grant permission to use photographs, quotes, academic accomplishments, statements and/or print my first and last name in any and/or all publications for Student Support Services.

Applications will be held for one year from date of application. Please reapply at that time.

I have read and agree with the Statement of Certification and the Statement of Agreement and Consent.

Student Signature

Date

mm-dd-yyyy

TRIO Student Support Services Intake Form

Education

Eligibility

Verification