Fillable SSS Application (Southern University at Shreveport)

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SSS Application (Southern University at Shreveport)

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SOUTHERN UNIVERSITY AT SHREVEPORT
TRIO STUDENT SUPPORT SERVICES
PARTICIPANT APPLICATION
The Southern University at Shreveport Student Support Services (SSS)
Program is a federally funded TRiO Program under the U.S. Department of
Education that aids students in graduating from college. Program participants
must meet certain requirements set forth by the Department of Education. To
determine your eligibility, please fill out the following information completely.
The information you provide is strictly CONFIDENTIAL. In order for your
application to be reviewed, you must also attach a signed copy of your
latest 1040 income tax form, FAFSA, or other proof of income as well as
an unofficial academic transcript.
You must make an application intake appointment. If you cannot attend that
appointment, you will need to reschedule. If both appointments are missed,
your application will not be reviewed and you will not be considered for
enrollment into the program.
In accordance with 20 U.S.C. § 1232g; 34 CFR Part 99, the Family Education
Rights & Privacy Act (FERPA), the information provided will be used to
determine program eligibility, services needed and to evaluate participant
progress. Information from this document will remain confidential, retained in
the students’ program file and used to comply with required U.S. Department
of Education performance reporting.
Application will be on hold if all required documents are not received.
Sign and return the
completed application with all
required documents to:
Student Support Services
Fine Arts, C-15
3050 Martin Luther King, Jr.
Shreveport, LA 71107
If you have any questions or
to make an appointment,
contact the TRiO SSS office
at 318.670.9306
Or visit
www.susla.edu/page/student-
support-services
Our SSS Program serves a limited number of students every year and applying to the program does not guarantee
acceptance. Applications are evaluated on the number of available slots, individual academic need, motivation, and
federal eligibility. Program participants must be a U.S. citizen or permanent resident, enrolled in an Associate’s Degree,
Certificate or Diploma program at SUSLA, demonstrate academic need for services and meet at least one of the
following criteria:
Low-income student according to guidelines established by the U.S. Department of Education and verified by
SSS
First generation college student: a student where neither (custodial) parent has received a four-year degree
College student with documented disabilities: as defined in the American with Disabilities Act (ADA) and
verified by the SUSLA Office of Disability Services
Veteran
When there is limited space in the TRIO SSS program, priority will be given to:
Veterans
Alumni of other TRIO programs: Upward Bound, (Educational) Talent Search, Educational Opportunity Centers
(EOC), or other Student Support Services programs
Students who are both income-eligible and first-generation college students
SSS Grant Aid: Applicants accepted into the program must maintain an active status in the program to be eligible to
apply for Grant Aid. Additional grant aid criteria may be found on the Grant Aid application. The application will
be available beginning eight weeks after the start of the fall and spring semesters.
SUSLA TRiO Student Support Services does not discriminate on the basis of race, age, color, national origin, gender, or disability.
This project is 100% federally funded.
Student ID#
Date of Birth
Gender
Street Address/PO
City
Zip Code
State
Cell Phone Alternate Phone
School Email
Alternate Email
Citizenship Status
Credit Hours Earned
Enrollment Status
Have you ever participated in one of the following programs? Select all that apply.
Ethnicity/Race
Classification
.Do you have a prior degree?
ACT/SAT Score
Which did you receive?
HS G.P.A.
High School Graduation Date
PART 1: DEMOGRAPHIC DATA
Name: ______________________________________________________________
First MI Last
____Female _____Male
( )
( )
(SSS may communicate with you via your home address, email, home number or text to notify you of upcoming events and workshops with the program.)
___American Indian/Alaskan Native ___Asian ___Black/African-American ___Hispanic or Latino
___Native Hawaiian, Pacific Islander or Other ___White ___More than one ethnicity/race ___Other: ___________
Are you registered with the Office of Disabilty Services
with a documented disability? _____Yes _____No
Are you a homeless or foster care student?
_____Yes _____No
_____Incoming Freshman _____2
nd
Semester Freshman _____Sophomore _____Transfer Student
_____Full-time (12+ hours) ____3/4 time (9-11 cr. Hours) _____½ time (6-8 hours) ___Less than ½ time
____Educational Talent Search ____Educational Opportunity Centers (EOC) ____Upward Bound ____GEAR UP
____Student Support Services If so, where? __________________________________________________
PART 2: ELIGIBILITY INFORMATION
_____U.S. Citizen
_____Permanent
Resident (Non-U.S. Citizen with
permanent resident status)
____High School ____Some College
____Associate Degree ____Bachelor’s Degree
____Master’s Degree ____Ph.D./Ed.D.
____High School ____Some College
____Associate Degree ____Bachelor’s Degree
____Master’s Degree ____Ph.D./Ed.D.
Financial
Aid Status
_____Dependent Student- Claimed by
parent(s) or other person(s)
____Independent Student- 25 year old or older or
married, a veteran or active military, have children who
receive more than half of their support from you, if you
are an orphan or ward/dependent of the court.
Are you receiving financial aid? ____Yes
____No
Income
Verification
Household size:
_______
_____I attest that my family did not file
a federal income tax return for the last
calendar year: Unemployment
Compensation, Social Security, TANF,
Veteran’s Payments, Welfare,
Vocational Rehabilitation Funds
Tax Return Year 20_____
Federal Taxable Income $_______________________
Note: Your taxable income can be found on the federal tax return you
filed for the last calendar year. On IRS Form 1040, see line 43. On IRS
Form 1040A, see line 27. On IRS Form 1040EZ, see line 6. On IRS
Telefile, see line K1.
SIGNED copies of your income tax forms or income verification are required to determine eligibility.
Educational
Background
____HS Diploma ___GED/HiSET ____N/A
_____Associate’s Degree _____Bachelor’s Degree _____No
OR
PART 3: EDUCATIONAL OBJECTIVE
Major:
Anticipated Graduation Date
Do you plan to transfer to a four-year university? If yes, what are your choices?
____Yes ___No
What is your career goal?
PART 4: SELF-IDENTIFIED NEEDS (CHECK ALL THAT APPLY)
___Academic Advising
___Career Planning/Goal Setting
___Test Taking Skills/Test Anxiety
___ Financial Aid/Scholarships
____Learning Styles/General Study
Skills
____Tutoring/Supplemental
Instruction
____Financial Literacy
____Time Management Skills
____Use/Access to Technology
____Leadership Development
____Transfer/Graduation Assistance
____Note Taking Skills
____Personal Concerns
____Math Anxiety/Access to
Graphing Calculators
____Social/Cultural Enrichment
____Child Care Assistance Other:_________________________________________________________
PART 5: HOW DID YOU HEAR ABOUT STUDENT SUPPORT SERVICES?
PART 6: PARTICIPANT AGREEMENT/RELEASE OF INFORMATION/AFFIDAVIT OF TRUTH
____(Initial) I understand that application into the SUSLA TRiO Student Support Services does not assure acceptance into the
program.
____(Initial) I am aware that personal information provided to the TRiO Student Support Services Program will be protected under the
Federal Education Rights & Privacy Act (FERPA). I hereby grant permission to Student Support Services to obtain requested information
from my personal file and student records (including enrollment, attendance, grades, financial aid, disability documentation, and student
employment) for the purpose of determining eligibility and helping me to succeed while enrolled at Southern University at Shreveport.
____(Initial) I agree to attend workshops, tutoring sessions, meetings and other events as requested by SSS to remain active in the
program. I also agree to allow SSS to use photos for recruitment and media opportunities.
____(Initial) I approve TRiO Student Support Services to send text messages to my cell phone in lieu of phone calls, in order to convey
program information. I understand that text messaging rates will apply to any messages received from the program. I also understand
that I, or the program, may revoke this permission in writing at any time. I agree not to hold SSS liable for any electronic messaging
charges or fees generated by this service.
I hereby certify, to the best of my knowledge, that all the information submitted is complete, true and correct. If asked by an
authorized official, I agree to provide proof of this information. I also understand that failure to disclose accurate information could
result in nonacceptance of the application or dismissal from the program.
____________________________________________________________
____________________
Applicant Signature
Date
For Office Use Only:
Date Application Received: _________________________________ Staff Initials _________________
Southern University at Shreveport does not discriminate on the basis of race, color, national origin, gender, age, disability or any other protected class.
Title IX Coordinator: Dr. Tuesday W. Mahoney, Johnny L. Vance, Jr. Student Activity Center, Room 208, (318) 670-9201.
Section 504 Coordinator: Ms. Jerushka Ellis, Health & Physical Education Complex, Room 314, (318) 670-9367.
SSS/sg 1_2021
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Completed 3 February 2021

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