Name: Last: _____________________________First: _________________________Middle: _________________
Address: Street _______________________________City ____________________State/Zip _________________
Telephone: Cell: ________________________Home: ____________________ Emergency: __________________
Email Address: School: ______________
Date of Birth: ___________________________
Other Email Address: ___________________________________________________________________________
Do you have a documented disability? ___ Yes ____No
If yes, would you like to request accommodations? _____ Yes _____ No
Race: (Check all that apply) ______ White ______ Black or African American
______ Native Hawaiian/Pacific Islander ______ Hispanic
______ American Indian/Alaskan Native ______ Asian
Citizenship: ____ U.S. Citizen ____ Permanent Resident #A_____________________________
Gender: ________ Female ________Male
Marital Status: ______Single ______Married ______ Separated ______ Divorced ______Widowed
Major: _____________________________Academic Advisor: ________________________________________
Year you plan to graduate from DSLCC____________
High School attended? ___________________________________________ Were you in Talent Search? _____
Did you graduate? ____ Yes____ No If yes, what year? ____________
If no, did you receive a GED? ____ Yes ____ No If yes, what year? ____________
Have you been out of school for more than 5 years? ____ Yes ____ No
Do you have a Bachelor’s Degree? ____ Yes ____ No
Who referred you to Student Support Services? ___________________________________________________
Can you think of anything that might keep you from completing your degree?
(Family, grades, social life, money, self-motivation, career decisions, other, please explain)
PART III: Family Information
Please answer the following questions about your parents and yourself:
Has your mother received a Bachelor’s Degree? _____yes ______no
Has your father received a Bachelor’s Degree? ______yes ______no
A. Check all that apply to you (the student) _______Over 24 years of age ________Armed Forces Veteran
______Ward of the state _____Provided dependency override by DSLCC financial aid office ____Both parents deceased
If you have dependent children (answer all that apply): How many children? _______ Are you a single parent? _______
Do you receive TANF? ______
If you checked any of the options above in part A, go to part C. If you did not, continue to part B.
B. Please indicate how many people are part of your household: Self ______Mother ______Father ______
Number of brothers and sisters _____ (you may count them if they are in college and your parents support them, even if
they do not live at home). Number of other dependents claimed on tax return__________
C. Total in household______
Part IV: Finances
Did you apply for (FAFSA) student financial aid? _________ Did you receive aid? _________
*What is your family’s taxable income (not total) from last year?
(Please check one and provide information)
_____ My family’s taxable income (not total) was $____________________
_____ My family did not file a federal income tax return for the last calendar year. My family’s total
income from the last calendar year was $_______________________
_____ My family had no taxable income during the last calendar year.
*Taxable income can be found on the federal income tax return: On IRS Form 1040, see line 43.
On IRS Form 1040A, see line 27. On IRS Form 1040 EZ, see line 6.
I authorize the Student Support Services staff at Dabney S Lancaster Community College to
obtain academic, financial aid, disability (if applicable), and other information pertinent to my participation in the
Student Support Services Program at DSLCC. I understand that these records will be used only to assess the
need for program services, discern educational progress, evaluate the effectiveness of the program activities,
and fulfill program reporting requirements.
In addition, I give permission for my photograph/video, work and/or statements to be used by Student Support
Services and/or the college for promotional or publicity purposes.
I affirm to the best of my knowledge that the information I have provided is true.
Student Signature: ______________________________________________________ Date: _________________
Parent/ Guardian Signature: _______________________________________________Date: _________________
Approved ______Not Approved ______Waiting List_______
Director’s Initials: ______
Project Entry Date: __________
Eligibility: LI/FG ______FG ______ LI _____ DS _____ LI/DS ______
Income Verification: FA _____ Tax _______
Academic Need: _____________________________________________________________________
DSLCC Student Support Services
Achievement Center 540-863-2860
Student Support Services is funded through the U.S. Department of Education TRIO programs for
$330,124. PO42A200564.
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Name ___________________________________________________________________
Program of Study at DSLCC_________________________________________________ Undecided
Do you intend to transfer to a four-year college/university? Yes No
If yes, which four-year schools are you considering?
_______________________________________________________________________ Undecided
Please check all needs that apply to you:
Improve writing skills Improve grade point average Receive transfer information
Improve general study habits Improve math skills Make career decisions
Improve note taking skills Improve vocabulary Plan college courses
Improve time management Increase reading speed Reduce math anxiety
Improve test taking skills Increase reading comprehension
Check any of the following items which describe you:
Out of school too long Panic during tests May need personal counseling
Afraid of failing in college Few computer skills Difficulty finding child care
Unsure of college procedures Little experience on the internet Difficulty managing money
Afraid I might not fit in Difficulty meeting new people Difficulty meeting deadlines
Difficulty participating in discussions
What obstacle(s) would most likely prevent you from completing your academic goals?
Poor study habits Bad grades Dealing with bills
Lack of money Easily distracted Family medical problems
Taking the wrong classes Problems at home Separation or divorce
Always worrying Trouble sleeping Recurring health concerns
Too shy Afraid to speak up in class Alcohol and/or drug problems
No home computer or laptop Feeling depressed or sad No support from family/friends
Limited or no internet access Taking things too seriously
Check any of the following items that apply to you:
I do not know my academic advisor.
I need help completing financial aid forms.
I need help selecting my courses and/or registering.
I am not familiar with the graduation application process.
I do not have a DSLCC student ID.
I am uncertain how to use the DSLCC library.
I am not familiar with Navigate, the DSLCC Web Page and/or Student Information System.
I need assistance with using Canvas.
I have not logged into my DSLCC student email.
Revised 8/27/2019