All information provided will
remain confidential and used only for: a.) Eligibility determination, b.) Student demographics, c.)
record keeping, d.) needs assessment, e.) federal reporting, f.) other administrative purposes
Date: _____________________ Semester: ______Fall ______Spring Year: 20______
Student Status: ______New Freshmen ______Re-Admitted ______Transfer ______Continuing
Name: _________________________________________________ DOB: ________________ Age: ______________
Gender: _____ SS# _________________ Tribal Affiliation: ________________________ U.S. Citizen: Yes No
Permanent (Home) Address: ________________________________________________________
(Street/PO Box)
Lawrence Address:_____________________________________________________ Marital Status: Single/Married
Phone Number: (_______)_____________________ Email Address:
On-Campus Information: Dorm: _________________________Rm. #___________ Haskell Box#________
Participation in other TRiO programs: (check all that apply & give approximate date)
____Talent Search ___Upward Bound ___SSS ___McNair Scholars
Degrees & Diplomas Held: (Check all that apply)
GED HS Diploma-Yr.______
Associate's Degree
BA, BFA, BS, BGS Master’s or Doctorate
Other: ___________________________
Haskell Classification: Freshman 
Junior Senior GPA: __________
Major: _______________________Have you applied for acceptance into this Haskell program? Y N
Income Status:
Are you receiving financial aid (i.e. PELL, etc) through the Haskell Financial Aid Office?
____ NO If no, why not? ___ Financial Reasons ___ Academic Reasons ___ did not apply for FAFSA
____UNSURE If unsure, why? ___Waiting for FAFSA results ___Need Assistance finding out
What is your Family Income per year? $ ____________ Family Size _______
First-Generation College Status:
Has your mother completed a bachelor’s degree or beyond? Y N Unknown
Has your father completed a bachelor’s degree or beyond? Y N Unknown
Or has your guardian completed a bachelor’s degree or beyond? Y N Unknown
Were you living with your mother prior to your 18
birthday? Y N
Were you living with your father prior to your 18
birthday? Y N
Were you living with your guardian prior to your 18
birthday? Y N
TRiO-Student Support Services
Haskell Indian Nations University
155 Indian Ave, Lawrence, KS 66046
Phone: (785) 749-8432 & (785)832-6670
Disability Status:
Do you have a disability? Y N
If so, is documentation regarding your disability filed with the university? Y N
*The disability coordinator is located in Tommaney Hall, room 132 (computer lab).
ACADEMIC NEED: (Choose one that best describes WHY you seek our academic services)
1.) Low H.S. gra
des ____ 7.) Out of the academic pipeline for 5+ years ____
2.) Low Admission scores ____ 8.) Limited English proficiency ____
3.) Predictive Indicator ____ 9.) Lack of educational/Career goals ____
4.) Diagnostic tests ____ 10.) Lack of preparedness ____
5.) Low college grades ____ 11.) Need to raise grades ____
6.) H.S. equivalency ____ 12.) Other: ___________________ ____
on of Accuracy: To the best of my knowledge, the above information is true and accurate. Initials________
Statement of Agreement & Consent: I authorize Haskell Student Support Services to gather my ACT scores, financial aid reports,
transcripts, and other necessary information, which will provide me with the services that I have requested. I authorize and
understand that TRiO SSS will continue to gather information regarding my transcripts and financial aid reports for the duration of
the time I attend Haskell, even if I choose not to utilize their services. I understand that the collected data, plus information I provide
on this form, will be used to make reports to the US Department of Education for the re-funding of this program. I also authorize
SSS to obtain periodic reports from my instructors regarding my academic progress for courses in which I am enrolled. I understand
that all information will be kept confidential and will be used for the purposes specified. My failure to adhere to the SSS policies is
possible dismissal from the SSS program.
Student Signature: ___________________________________________________ Date: ___________________
OFFICE USE ONLY: (please check) STATUS:
____ LI ____FG ____LI/FG ____Eligibility Not Met ____Accepted
____Pending (need more info.)
____ Wait List
SSS Signature: ______________________________________________________ Date: __________________
___ Disability
Update 7/2016
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome