Fillable AIO/DC Intake Form Date (Montana State University - Billings)

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AIO/DC Intake Form Date (Montana State University - Billings)

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AIO/DC Intake Form Date____________
Personal Information: Student ID: _______________
Name: _______________________________________Phone:___________________
Email: ________________________________________ Sex: Age:_____
Mailing Address: ________________________________________________________
City: __________________ ST: ___________ Zip: _________
I best describe my ethnicity as:
Tribe or country of origin:
LGBT:
I am a _________________ Student:
Major: Estimated GPA:
Transfer College:
What are your concerns about attending college at MSU Billings?
Money Classes Time Family Major Other
Please Explain:
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________.
List any barriers that you think may keep you from doing well:
1.__________________________ 3.__________________________
2.__________________________ 4.__________________________
List support systems or skills that will be helpful in your college success:
1.__________________________ 3.___________________________
2.__________________________ 4.___________________________
Unsure
AIO/DC Intake Form Date____________
Interest Inventory
Please indicate by checking those organizations or events you would be interested in
participating in this semester.
Intertribal Indian Club___ Amistad/Hispanic Club___ African American Club____
Pow Wow 2012___ Intertribal Clan Mothers___ LGBTA Club ___
Indian Heritage Day___ Medicine Wheel___
Please indicate interest in organizing a student club or event on campus:
Other_________________________________________________________________
Workshops:
Pow Wow NASX 494 (Credit Workshop):____
Applying for Scholarships:____
Other Workshop topics you would be interested in? :
______________________________________________________________________
______________________________________________________________________
How can MSU Billings serve you better in regards to diversity?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Would you be interested in an Internships____ or Work-study____ with American Indian
Outreach and Diversity Center?
Speakers Bureau:
Please indicate topics that you would be interested in presenting about. Please include
a preferred age group. Often, an honorarium and/or mileage are provided.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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AIODC Intake Form Date (Montana State University - Billings)

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Completed 23 July 2020

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