Washburn University Of Topeka-SSS-Application Form

Washburn ID# (WIN)

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

(999)999-9999

Emergency Contact Person

First NameLast Name

Emergency Contact Phone Number

(999)999-9999

Washburn Email*

example@example.com

Birth Date*

mm-dd-yyyy

Gender:*

MaleFemaleNon-binaryPrefer not to say

Pronouns

Hispanic/Latinx*

YesNo

Race*

Citizenship*

US CitizenPermanent Resident

If yes, please provide a copy of your birth certificate:

If no, Registration Card #

Are you admitted to Washburn University?*

YesNo

Are you currently enrolled at Washburn University?*

YesNo

Have you already completed a Bachelors degree?*

YesNo

Do you plan to earn a Bachelors degree from WU?*

YesNo

What year are you? (click all that apply)

Anticipated College Graduation Date

mm-dd-yyyy

College Major

Did your father receive a 4-year college degree?*

YesNo

Did your mother receive a 4-year college degree?*

YesNo

Did you complete a FAFSA?*

YesNo

Are you receiving a Pell Grant?*

YesNo

Are you currently receiving services from Washburn's Student Accessibility Office?*

YesNo

Are you receiving any of the following scholarships?*

Shawnee County Promise ScholarshipNortheast Kansas Advantage ScholarshipFinnup Scholarship

Have you ever or do you plan to participate in the Ichabod Success Institute early start program at Washburn?*

YesNo

Are you or will you be a graduate of Washburn's TRIO Upward Bound Program?*

YesNo

Were you a participant in another TRIO Program at a different school (not Washburn)? Check all that apply.*

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 belowI 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.

File Upload

Please check any statements you believe describe your academic needs:*

I am enrolling in Student Support Services for the following kinds of assistance (check all that apply):*

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*

mm-dd-yyyy

Washburn University SSS Application Form

General Information

Education Information

Eligibility Criteria

Needs Assessment