Fillable Sss Application (California State University Channel Islands)

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Sss Application (California State University Channel Islands)

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OFFICE USE ONLY - Date Received: _____ /_____ / _____ Initials: _________
Student Support Services - Application for Participation
Please indicate the term you are applying for:
Fall Spring Summer
STUDENT INFORMATION
Name (Last, First, Middle Initial) SSN
Address (Street & Apartment/Unit#)
City, State, Zip Code Student ID#
Home Phone Cell Phone
Gender:
Male Female
CI E-mail Alternate E-mail
Ethnic Identity:
White/Caucasian Black or African American Multi-Racial Hispanic/Chicano/Latino
AsianNative Hawaiian/Pacific Islander American Indian or Alaskan Native Other
If you marked "Other," please describe your ethnicity:
Current Class Standing:
Freshman Sophomore Junior Senior Transfer
Enrollment Status:
Full-Time Part-Time
Cumulative Grade Point Average (GPA)
As required by the U.S. Department of Education, please complete the following questions in order to be considered for the CSU Channel Islands
Student Support Services Program.
Student is:
U.S. Citizen Non-U.S. Citizen -
Resident Alien - Non-Resident Alien
Alien Reg. #:
Country of Citizenship:
FAMILY INFORMATION
Father/Guardian Phone
Occupation Work Phone
Father's highest level of education:
Elementary (grades K-6) Junior High (grades 7-8)
High School (grades 9-12) Community College (two-year degree) College Degree (four-year degree)
No Formal Education
Mother/Guardian Phone
Occupation Work Phone
Mother's highest level of education:
No Formal Education Elementary (grades K-6) Junior High (grades 7-8)
High School (grades 9-12) Community College (two-year degree) College Degree (four-year degree)
Please indicate the year you are applying for:
FINANCIAL INFORMATION
Please list the total number of people in your household
Have you applied for financial aid for the current academic year?
Yes No
Were you awarded financial aid for the current academic year?
Yes No
Are you Dependent or Independent*, as defined by Federal Student Aid?
Dependent Independent
*An independent student is one of the following: at least 24 years old (born before Jan. 1, 1988), married, a graduate or professional student, a veteran, a member of the
armed forces, an orphan, a ward of the court, or someone with legal dependents other than a spouse.
If Dependent:
1. Did you or your parents file a tax return for the previous federal income tax year?
Yes No, but I intend to file No, I was not required to file.
2. Please indicate your family’s taxable income (refer to the previous year’s federal income tax return - 1040: line 43,
1040A: line 27, 1040EZ: line 6):
If Independent:
1. Did you file a tax return for the previous federal income tax year?
Yes No, but I intend to file No, I was not required to file.
2. Please indicate your taxable income (refer to the previous year’s federal income tax return - 1040: line 43, 1040A:
line 27, 1040EZ: line 6):
3. Are you currently employed?
Part-time Full-time Not Employed
If yes, where?
OTHER INFORMATION
Do you have any physical or learning disabilities?
Yes No
Do you receive services from Disability Resource Programs (DRP)?
Are you a veteran of the armed forces?
Yes No
Is English your primary language?
Yes No
Are you currently in EOP or EOPS?
Yes No
Have you previously participated in a TRiO program (e.g., Upward Bound, Talent Search)?
Yes No
How did you hear about Student Support Services (SSS)?
Friend Faculty/Staff Brochure Other
If you selected "Other," please explain:
What services are you interested in? This information is required; please check all that apply.
Individualized Counseling Career Planning Tutoring Educational Workshops
Writing SkillsGraduate School Preparation FAFSA Assistance Cultural Enrichment
Yes No
If no, please list your primary language:
CONFIRMATION OF INFORMATION AND AUTHORIZATION FOR RELEASE
I understand that the personal information given to California State University Channel Islands’ Student Support Services (SSS) Program is
protected by the Family Educational Rights and Privacy Act and will be kept confidential. I authorize the CSU Channel Islands SSS Program
to receive copies of my transcripts, grade reports, financial aid awards, and other records necessary for application review, if accepted, and
for continued program participation. In addition, I hereby give permission for my name, photograph, work and/or statements to be used
by SSS for promotional, publicity or instructional purposes.
I confirm that all of the information contained within this application is complete and accurate to the best of my knowledge.
Student Signature:
Date:
Please submit completed application to the Student Support
Services office located at Bell Tower 1858.
You may also mail your application to:
California State University Channel Islands
Student Support Services Program
One University Drive
Camarillo, CA 93012
Or, fax application to (805) 437-3211 – Attn: SSS Center.
If you have any questions or concerns regarding the
application process, please contact us at (805) 437-3560
or via email at sss.center@csuci.edu.
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Sss Application (California State University Channel Islands)

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Completed 19 July 2020

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