Name: __________________________________________________________________________________________________________
Last First Middle Maiden
Student ID: _______________________________________ DOB: _______________ Age: _________ Sex: M F
Marital Status: Single Married Single Parent Divorced Legally Separated Widowed
U.S. Cizen: Yes No OR I have a permanent Visa, Alien Registraon #: ______________________ Veteran: Yes No
Race: American Indian/Alaskan Nave Asian Black or African-American Nave Hawaiian or Other Pacic Islander White
Ethnicity: Hispanic or Lano Yes No
At the me of your 18th birthday, did either of your parents have a Bachelors Degree (4 year)? Yes No
If YES, what was the degree in (or their current occupaon): ______________________________________________________________
Do you have a High School Diploma or GED Date Received (YEAR): ________ Place Received (CITY, ST): ____________________
Do you have a DIAGNOSED Physical OR Learning Disability? Yes No
If yes, specify _____________________________________________________________(You must provide us with documentaon of your disability.)
Have you been in a TRIO Program before? Yes No
If Yes, which: SSS EOC Gear Up Veteran's Upward Bound Talent Search Upward Bound
Class Status: FR (0-29 credits) SO (30-59) JR (60-89 credits) SR (90+ credits) Major: _______________________________________
Local Address:
_______________________________________________________________ ___________________ ____________ ___________
Address City State Zip
Permanent Address:
_______________________________________________________________ ___________________ ____________ ___________
Address City State Zip
Home Phone: ________________________ Cell Phone: ________________________ Email:_________________________________
On 2017 income taxes, were you a: Dependent (I am included on my parents’/guardian's taxes) Size of Family Unit:___________
Independent (I cannot be claimed on someone elses taxes) Income for 2017:______________
Do (or will) you receive any of the following nancial aid programs? Yes No
If yes, which one(s): Pell FSEOG BIA FDSL V.A. TANF Voc. Rehab
MTHEG Social Security Work-Study JTPA
I hereby grant permission to MSU-Northern Student Support Services to secure the necessary informaon pernent to my parcipaon in the SSS Program and MSU-
Northern (e.g. nancial data, standardized test scores, college/high school transcripts, instructor contact, and disability services). Please note that you only need to apply
ONCE to be considered for the TRIO SSS program. I cerfy the above informaon to be true to the best of my knowledge.
_____________________________________________________________________________ ______________________
Students Signature Date
_____________________________________________________________________________ ______________________
SSS Directors Signature Date
All informaon is condenal. Only aggregate (total/subgroup) data will be used for purposes of federal grant compliance.
Student Support Services
Cowan Hall Rm 211 T: (406)265-3783 F: (406)265-3508
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Selecon Criterion for SSS Parcipaon
* Low-Income, First-generaon, Disability Status
* Educaonal Need as evidenced by low high school GPA
* Educaonal Need as evidenced by low cumulave college GPA
* Academic Remediaon as evidenced by placement in developmental courses
* Academic Remediaon as evidenced by low standardized entrance exams
* Disadvantaged Educaonal Background as evidenced by aendance at reservaon high school
* Disadvantaged Educaonal Background as evidenced by a GED
* Economic Disadvantaged as evidenced by unemployment, single head-house-hold, displaced worker
* Economic Disadvantaged as evidenced by family, personal income
* Educaonal Barriers as evidenced by physical & learning disabilies
* Ability to Benet from Project evidenced by referral from faculty, sta, or other professionals
* Movaonal as evidenced by personal level of interest in SSS services expressed on the applicaon
or during the intake interview
* Movaon as evidenced by feedback from faculty, sta, or other individuals about the applicants
level of movaon in class or during other acvies.
* Willingness to parcipate in Freshman SSS Super Week and three Life Skills Work Shops annually.
Upper class agree to at least 3 coaching session.
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