TRiO - Student Support Services Application
STEP 1 – Personal Data
Name
*
First Name
Middle Name
Last Name
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your home phone number?
*
(999)999-9999
What is your cell phone number
*
(999)999-9999
Can we please text you?
*
Yes
No
What is your student e-mail address?
*
example@example.com
What is the best way to contact you?
*
Email
Call
Text
What is your G# ID number?
*
What is your birth date?
*
-
Month
-
Day
Year
Date
Are you a United States citizen or permanent resident with a Green Card?
*
Yes
No
What was your sex assigned at birth?
*
Female
Male
STEP 2 – Ethnic Background
Do you identify as Hispanic or Latino?
*
Yes
No
What is your ethnicity? Mark all that apply. (Please select at least one)
*
American Indian
Alaskan Native
Native Hawaiian or Other Pacific Islander
Asian
White/Caucasian
Black or African American
STEP 3 – Parental Information
Highest grade completed by mother?
*
Elementary
High School
Some College
Received 4-yr degree
Highest grade completed by father?
*
Elementary
High School
Some College
Received 4-yr degree
Which parent did you regularly reside with and receive support from during yourchildhood (i.e.: until you were 18 years old)?
*
Both
Mother
Father
STEP 4 – Financial Information
Marital Status:
*
Single
Married
Divorced/separated
How many people live in your household?
*
Are you receiving Financial Aid at Guilford College?
*
Yes
No
Not Sure
Do you receive the PELL Grant?
*
Yes
No
Not Sure
STEP 5 – Background Information
Are you married?
Yes
No
Do you have children?
Yes
No
Are you a U.S. Armed Forces veteran?
Yes
No
Are you serving on active duty in the US Armed forces?
Yes
No
Are/were you an orphan, in foster care, or a ward of the court?
Yes
No
Are/were you an emancipated minor or did you have a court-appointed legal guardian?
Yes
No
Do you have a diagnosed disability? (Physical, learning, and/or psychological)
Yes
No
If you indicated that you have a diagnosed disability above, have you registered with the ARC office?
Yes
No
STEP 6 – Services You May Need (Check ALL that apply
Tutoring Assistance
Math
English/writing
Sciences
History
Political Science
Business
Other
Counseling/Advising:
Academic
Transfer/admission
Financial aid
Career & Personal
Academic Challenges:
Study skills
Time management
Financial
Organizational skills
Stress/worrying
Personal/living environment issues
Lack of support network
Unclear objectives/goals
STEP 7 – Educational Information
Did you graduate from high school? (NOTE: TRiO SSS cannot serve students whohaven't completed high school or earned a GED)
Yes
No
Do you plan on attending grad school or professional school after receiving your 4 yr Degree?
*
What is your current major?
STEP 8 – Other Programs
Do you participate in another a program or sport on campus?
STEP 9 – Acknowledgement
Please read the following statement and then sign and date below it. If you (thestudent) are under 18, your parent or legal guardian must also read the followingstatement and then sign and date below.By signing this application, I attest that all the information on this application is true.Moreover, I authorize the release of the student’s official academic records to theTRiO/SSS program, understanding that the information in these records will be usedonly to assess the student’s need for program services, discern the student’seducational progress, evaluate the effectiveness of program activities, communicatewith the student, and fulfill program-reporting requirements.
*
What is today's date?
-
Month
-
Day
Year
Date
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