Emporia State University
Student Support Services Intake Form
1 Kellogg Circle, Campus Box 05 323 South Morse Hall 620-341-5097
Full Legal Name
Preferred First Name
Social Security No.
ESU Student ID:
Campus Address:
do not leave blank.
College Address (Where you live while at ESU - Residence Hall & Room, local address, or same as Perm. Address”)
Cell Phone:
Home Phone:
Perm Address:
(indicate if same as campus address)
Street Address; City, State Zip
Campus Email: Personal Email:
Date of Birth: Gender: Male Female
How do you prefer to be contacted: Email Text Both
Marital Status: Single Married Divorced Separated Widowed
Ethnicity: The USDE requires institutions to collect data on race and ethnicity.
Do you consider yourself Hispanic/Latino?
Yes No (If Yes, please also check one of the “RACE” options below)
Race (Please check any and all that apply
American Indian/Alaskan Asian Black or African-American Native Hawaiian/Pacific Islander White
Date you first enrolled or started at ESU?
Are you a U.S. Citizen? Yes No If No, are you a permanent resident? Yes No
Have you participated in other Educational Opportunity Programs (i.e., AVID, GEAR UP, Talent Search, Upward Bound
(i.e., AVID, GEAR UP, Talent Search, Upward Bound)? Yes No If yes, name?
Declared Major: undecided
If you are a transfer student, what school have you transferred from:
How many hours are you transferring to ESU (if you know)?
Do you plan to complete your degree at ESU? Yes No
1. Did either parent or legal guardian(s) with whom you regularly reside receive a
4-year college degree before you turned 18?
Yes No
2. Will you be or are you currently receiving financial aid through the ESU Financial Aid Office? Yes No
If NO, why? Not eligible Have not applied but will apply for this year Financial reasons Academic reasons
Other (please explain)
3. Do you have a learning or physical disability? Yes No
If Yes, will you or have you filed for services with ESU’s Student Yes No
Accessibility and Support Services (SASS) Office?
For Office Use
Needs Done
Request Advising Folder
Make changes to schedule
New schedule sent
Sign up for tutoring
Verify income status
Verify FG status
Needs NP Appt. w/Nyk
Date: ___________________
For Office Use
Eligibility: __________
Need: __________
For Office Use
Email Groups
INB Attribute
Advising List
HC Date ____________
If you don't know your campus address yet, just write "Campus" for now and we will look it up or get it later.
As a federally funded program, TRIO Student Support Services (SSS) is required to provide documentation of students’ program
eligibility. One important aspect of eligibility is verification of “Family Income.” Verification requirements vary depending on
whether students are independent or dependent. (A list of criteria for independent student status is available at
Read each option below, then check and complete ONE of the following based on your status:
I am a dependent student (younger than 24: unmarried/not emancipated; parental income reported on the FAFSA):
Parent/guardian must complete and sign or provide a copy of most recent tax return.
Number of people support by the family unit:
Parent/guardian’s Taxable Income (not adjusted gross) for the previous year:
Did not file. Total income for previous year:
Parent/Guardian Signature
I am an independent student (typically 24 or older or married/emancipated; parental income not reported on the FAFSA).
Student must complete and sign or provide a copy of most recent tax return
Number of people support by the family unit:
Student’s Taxable Income (not adjusted gross) for the previous year:
Did not file. Total income for previous year:
I DECLINE to provide my financial information, but would still like to be considered for the SSS program.
Statement of Verification
To the best of my knowledge, all information provided on this application is true and complete.
Statement of Agreement and Consent
I understand that the SSS program will use the data provided on this form to assist in determining eligibility and all
information will be kept confidential.
I authorize Emporia State University Student Support Services to gather my high school and college transcripts,
placement scores, FAFSA and scholarship information, disability documentation, ACT scores, and other necessary
information in order to provide the services I have requested, and to make reports to the U.S. 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, as well as obtain college enrollment and degree
information from National Student Clearinghouse. I understand that all information will be kept confidential and will
be used for the following specified purposes:
a. student demographic data and record keeping d. federal reporting
b. program evaluation e. other administrative purposes
c. needs assessment
I grant permission to use photographs, quotes, academic accomplishments, statements and/or print my first and last
name in any and/or all publications for Student Support Services.
Applications will be held for one year from date of application. Please reapply at that time.
I have read and agree with the Statement of Verification and the Statement of Agreement and Consent.
Student Signature
Please return this form by mail to:
TRIO Student Support Services
Emporia State University
1 Kellogg Circle, Campus Box 4005
Emporia, KS 66801
or hand deliver to:
323 South Morse Hall
or email to:
or fax to:
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