Fillable Application For Services-Editable

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Application For Services-Editable

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  • 60 check-boxes
  • 109 other fields

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File type: PDF

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Application for Project
Services
Name: _________________________________________________ My WSU ID: ____________
__________
SSN: ______________________ Birth date: _________________(Month/Day/Year)
Address: _____________________________________________________________________________
Street City State Zip
Phone: ____________________________ E-mail: _______________________________
Facebook Name: _____________________________________
College Level:
Citizenship:
Freshman
Sophomore
Junior
Senior
U.S. Citizen
Permanent Resident
Resident Alien Number:
________________
Gender:
Degree:
Male
Major: ____________
Female
Minor: ____________
Are you a single parent?
Yes
No
If Yes, how many
children do you have? ___________
Emergency Contact
Contact Person: _________________________________
Ethnicity: Are you Hispanic/Latino?
No, I am not Hispanic/Latino
Yes, I am Hispanic/Latino
Race: What is your race? (Check all that apply)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Subm
it Application in 309 Grace Wilkie Hall, M-F, 8:00AM-5:00PM, or via email to trio.sss@wichita.edu
Student Support Services, Wichita State University, 1845 N. Fairmount, Campus Box 81
Wichita, KS 67260-0081, (316) 978-3715, Fax (316) 978-3115
Eligibility
Yes
No
Yes
No
Did you complete a FAFSA?
Yes
No
Are you receiving a Pell Grant?
Yes
No
Are you receiving services from Disability Services and/or Disability Support Services?
Yes
No
TRIO Status
Have you previously participated in any of the following TRIO or GEAR-UP programs?
Yes
No
Check all that apply:
Student Support Services
Upward Bound
Communication Upward Bound
Talent Search
Upward Bound-Math/Science
McNair Scholars Program
Disability Support Services
Veterans Upward Bound
Educational Opportunity Centers
Gear-up
Phone: ____________________________
Academic Status
Are you an Incoming Freshman?
Yes
No
Are you a transfer student?
Yes
No
Do you plan to earn a bachelor’s degree from WSU?
Yes
No
Target graduation date? ____________________
I a
m
en
ro
l
l
ing in Student Support Services for the following reasons:
(Check all that apply)
Academic advising
Scholarship assistance
Tutoring assistance
Financial literacy development
Study skills development
Career advising
Financial aid advising
Graduate School advising
FAFSA application assistance
Personal advising
Statement of Certification:
I certify 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.
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.
Signature: __________________________________________
Date: ________________________
SSS Academic
Advisor Signature: ____________________________________ Date Enrolled: __________________
For your application to be complete, you must attach:
a copy of your most recent 1040 income tax form
(or your parent’s if you were claimed as a dependent)
a copy of your most recent transcript (high school or college)
your scores from the VARK Questionnaire found at http://vark-learn.com/the-vark-
questionnaire/
(print the page with your scores if submitting a paper application; save and attach a screenshot of your scores if
submitting an electronic application)
Academic Skills Needs Assessment Worksheet
Contact the Student Support Services office if you have questions regarding these items.
Student Support Services is a Federal TRIO Program, 100% funded through a grant from the United States Department of Education. Student Support Services receives EOF funding from SGA
and additional scholarships from community donors. Notice of Nondiscrimination: Wichita State University does not discriminat e in its pro-grams and activities on the basis of race, religion,
color, national origin, gender, age, sexual orientation, marital status, political affiliation, status as a veteran, or disability.
The following person has been designated to handle inquiries regarding nondiscrimination policies: Director, Office of Equal Employment Opportunity, Wichita State University, 1845
Fairmount, Wichita KS 67260-0205; telephone (316) 978-6791. Revised: 10/2017
Student Support Services
Academic
Skills Needs Assessment Worksheet
Effective study habits can reduce stress and ensure college success. Fill the circle that best describes your
current basic academic skill level for each skill using the rating scale from very weak to very strong.
Very Weak Neutral Strong Very
Weak Strong
Memory skills
Listening with comprehension
Taking notes in class
Learning facts and concepts from textbooks
Understanding what I read
Understanding math concepts
Access to computers
Competence on computer
Managing my time wisely
Speaking in front of a group
Studying for tests
Taking tests
Writing papers
Preparing a resume
Organizing my study space
Conserving my energy for appropriate activities
Attending class
Studying for more than 3 hours a day
ModifiedfromFloridaAtlanticUniversity’sStudentAcademicSkillsNeedsAssessmentWorksheet: RevisedSummer2016StudentSupportServices, WichitaStateUniversity
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Application For Services-Editable

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Completed 21 March 2020

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