Washburn University SSS Application Form
General Information
Washburn ID# (WIN)
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
(999)999-9999
Emergency Contact Person
First Name
Last Name
Emergency Contact Phone Number
(999)999-9999
Washburn Email
*
example@example.com
Birth Date
*
-
Month
-
Day
Year
mm-dd-yyyy
Gender:
*
Male
Female
Non-binary
Prefer not to say
Pronouns
He/Him
She/Her
They/Them
He/They
She/They
Other
Hispanic/Latinx
*
Yes
No
Race
*
White/Caucasian
Black or African American
Native American or American Indian
Native Hawaiian or Pacific Islander
Asian or Asian American
Prefer not to disclose
Citizenship
*
US Citizen
Permanent Resident
If yes, please provide a copy of your birth certificate:
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If no, Registration Card #
Education Information
Are you admitted to Washburn University?
*
Yes
No
Are you currently enrolled at Washburn University?
*
Yes
No
Have you already completed a Bachelors degree?
*
Yes
No
Do you plan to earn a Bachelors degree from WU?
*
Yes
No
What year are you? (click all that apply)
Freshman
Sophomore
Junior
Senior
High School Senior
Transfer Student
First-Year Student
Anticipated College Graduation Date
-
Month
-
Day
Year
mm-dd-yyyy
College Major
Eligibility Criteria
Did your father receive a 4-year college degree?
*
Yes
No
Did your mother receive a 4-year college degree?
*
Yes
No
Did your parent or guardian receive a 4-year college degree?
Yes Parent/Guardian 1 did receive a bachelor's degree
No Parent/Guardian 1 did not receive a bachelor's degree
Yes Parent/Guardian 2 did receive a bachelor's degree
No Parent/Guardian 2 did not receive a bachelor's degree
Neither Parent/Guardian received a bachelor's degree
Did you complete a FAFSA?
*
Yes
No
Are you receiving a Pell Grant?
*
Yes
No
Are you currently receiving services from Washburn's Student Accessibility Office?
*
Yes
No
Are you currently registered with Washburn University’s Student Accessibility Services Office for accommodations related to a mental, physical, or intellectual disability as defined by the Americans with Disabilities Act?
Yes
No
Unsure
If yes, I authorize TRIO to verify my disability documentation submitted with the WU Student Accessibility Services Office.
Yes
No
Are you receiving any of the following scholarships?
*
Shawnee County Promise Scholarship
Northeast Kansas Advantage Scholarship
Finnup Scholarship
None
Have you ever or do you plan to participate in the Ichabod Success Institute early start program at Washburn?
*
Yes
No
Are you or will you be a graduate of Washburn's TRIO Upward Bound Program?
*
Yes
No
Were you a participant in another TRIO Program at a different school (not Washburn)? Check all that apply.
*
Upward Bound
Upward Bound Math/Science
Veteran's Upward Bound
Student Support Services
Disability Student Support Services
Talent Search
Gear Up
McNair Scholars
EOC
I have not participated in another TRiO program.
For your application to be complete, Washburn SSS must receive your most recent (or your parents' most recent) 1040 tax form so we can determine your eligibility for program services. If available, please attach a copy of the 1040 tax form below. If you do not attach a copy to this application, please note that your application will be incomplete until you email a copy to diana.harvey@washburn.edu or deliver a physical copy to the Center for Student Success and Retention (Plass 315).
*
I am attaching a copy of my (or your parents') most recent 1040 tax form below
I will email a copy to sss@washburn.edu or deliver a copy to the Center for Student Success and Retention (Plass 315). I understand that my application is incomplete until I submit my tax form.
I will self report line 15 on my (or my parents) 1040 tax form.
LINE 15 of 1040
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Size of family unit: How many members are in your household?
Needs Assessment
Please check any statements you believe describe your academic needs:
*
I am, or believe I will, struggle in entry level classes like English, Math, or Biology
I have withdrawn from at least one college-level class because I wasn't doing well in it
I feel like I need extra support in my transition from high school to college
I am not confident about how to file my FAFSA
I am not confident about how to pay for college
I work 20 or more hours per week off campus
I don't feel like I have the knowledge or skills for navigating college systems or policies
I have elevated family responsibilities outside of school
I would benefit from a more robust support system
I am (or was) a foster care youth, homeless, or an otherwise disconnected student
English is not the primary language spoken at my home, or, I have taken English as a Second Language (ESL) classes
I have not decided on a major, or don't feel confident in my current one
I need help with academic planning
I need help deciding on a career or career pathway
I need help with career planning
I do not feel confident in my financial literacy skills such as budgeting, managing debt, planning for retirement, etc.
I am enrolling in Student Support Services for the following kinds of assistance (check all that apply):
*
Academic Advising
Tutoring Assistance
Study Skills Development
Financial Aid Advising
FAFSA application assistance
Scholarship assistance
Financial Literacy development
Career Advising
Graduate School Advising
Success Coaching
Assistance with Disability Services
Please tell us in 500 words or less why you are interested in joining TRIO Student Support Services. Students who evidence the motivation to succeed in college and a strong desire for program services will be given higher consideration for program admission.
*
Statement of Certification: I certify, under penalty of perjury, that all the information on this form is true and accurate to the best of my knowledge. I also authorize SSS permission to obtain and review any academic and financial documents needed to complete the application process.
*
Check this box for verification of the above statement.
Statement of Agreement & Consent: I grant permission to SSS, its representatives and employees, to take photographs of me and my property in connection with all SSS TRIO-related activities. I authorize SSS, its assignees and transferees to copyright, use and publish the same in print and/or electronic media. I agree that SSS may use such photographs of me with or without my name for lawful purposes, including, but not limited to, publicity, advertising and web content in connection with SSS.
*
Check this box if you AGREE to allow your photo to be used for SSS TRIO publications.
Check this box if you DO NOT want your photo used in SSS TRIO publications.
By checking the box, I certify that I would like to become a member of the Washburn University Student Support Services Program and consent to my information to be used within Student Support Services for this purpose
*
Check this box for verification of the above statement.
Signature
*
Today's Date
*
-
Month
-
Day
Year
mm-dd-yyyy
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