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TRiO Program Application Student Support Services (Texas A&M International University)

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TRiO SSS PY5 v3.1 04/24 1
TRiO
Student Support Services
Program Application
EQUAL OPPORTUNITY ADMISSION: TRiO Student Support Services is committed to servicing all persons
seeking academic support, and we encourage applications from students of diverse backgrounds. No distinction
is made upon the basis of race, color, disability, religion, age, gender, sexual orientation, marital status or life
circumstance.
I. Student Information
1. First Name__________________ Middle Name______________ Last Name______________________
2. SS#: _____ - _____ - _____ DOB: ________________ TAMIU Student ID #____________________
3. Local Address:___________________________City_____________State_____Zip Code___________
4. Home Phone: ___________________________ Cellular Phone: _______________________________
5. Permanent Address: _______________________City_____________State_____Zip Code___________
6. Email Address: _________________________________@dusty.tamiu.edu
7. Personal Email:_________________________________@____________________________________
8. Gender:____Male ____Female
9. Marital Status:____Single ____Married ____Divorced ____Widow/er
10. Citizenship Status:____U. S. Citizen ____Resident Alien ____Resident Alien Card #______________
11. Race/Ethnicity: ___Hispanic ___Black or African American ___American Indian
___White ___Asian ___Hawaiian or Pacific Islander
12. Are you currently employed?____Yes ____No
a. If yes, are you employed at TAMIU as a federal work study ____Yes ____No
b. If yes, are you employed at TAMIU as a staff employee ____Yes ____No
c. If yes, are you employed at TAMIU as Aramark/Book store employee ____Yes ____No
d. If yes, are you employed outside of TAMIU ____Yes ____No
13. What is the average number of hours that you work per week: _______
14. A first-generation college student is one whose parent(s) have not earned a 4 year (baccalaureate)
degree. Are you a first-generation college student?____Yes ____No
15. Name of High School Attended: ____________________________ City: _________ State: _________
16. Year graduated from high school: ________________ high school GPA: ___________
17. Please indicate if you have participated in any of the following program(s). Please check all that apply:
___Upward Bound ___Upward Bound Math/Science ___Talent Search ___E.O.C.
___Student Support Services ___McNair ___CAMP ___Other:__________________________
II. Enrollment Status
18. What is your current classification?
a. ___1st year, never attended before (no college credit)
b.___1st year (have earned college credits) (0-30hrs)
c.___2nd year/sophomore (31-60hrs)
d.___3rd year/junior (61-90hrs)
e.___4th year/senior (91-120hrs)
f.___5th year/other undergraduate (over 120hrs)
TRiO SSS PY5 v3.1 04/24 2
19. Are you transferring from another college/university?____Yes ____No
20. If yes, which college/university?__________________________________________________
21. Are you attending school: ___Fulltime (at least 12hrs credit a semester)
___3/4 time (at least 9hrs credits a semester)
___1/2 time (at least 6hrs credits a semester)
___Less than ½ time (fewer than 6hrs credit hours a semester)
22. What is your major?_________________________ or are you undeclared:_______________
23. What is your minor (if applicable)? _______________________
24. How many hours are you currently enrolled in?____ Which semester? ___fall ___spring ___summer
25. As a high school student, did you enroll in a college or university for course credits? ___Yes ___No
a. Did you receive college course credits for classes taken at your high school? ___Yes ___No
b. Did you receive college course credits for classes taken at a college or university?___Yes ___No
c. Were you a student of an Early College High School?___Yes ___No
d. Were you a student of an academy embedded within a college or university?___Yes ___No
26. What was your GPA for the college or university course(s) that you took while in high school? ______
27. ACT Scores: Composite_____ English_____ Math_____ Reading_____ Science & Reasoning____
28. SAT Scores: Composite_______ Reading/Writing_______ Math_______ Essay_______
29. TSI Scores: Math _________ Reading _________ Writing________
30. STAAR (EOC): Alg. II lvl 2_______ Eng. III/Rdg lvl 2_______
III. Financial Information
31. Have you applied for financial aid? ___Yes ___No
32. If yes, have you been awarded financial aid? ____Yes _____No
33. Please check the types of financial aid that was awarded to you:
___Pell Grant
___Texas Grant
___Subsidized Loan
___Unsubsidized Loans
___GI Bill Scholarships
___TASFA
___Other, explain_______________________
34. Did YOU file an income tax return (IRS Form 1040 or 1040 EZ)? ____Yes ____No ____Will file
35. If you filed an income tax return last year, what was your adjusted gross income? (IRS Form 1040 line 7
or IRS Form 1040EZ line 4) $________________
36. What was your taxable income? (IRS Form 1040 line 10 or IRS Form 1040EZ line 6) $ ____________
37. Did YOUR PARENTS file an income tax return (IRS Form 1040 or 1040 EZ)?
___Yes ___No ___Will file
38. Did your parent(s)/guardian claim you as a dependent? ___Yes ___No
TRiO SSS PY5 v3.1 04/24 3
39. If your parent(s)/guardian filed an income tax return last year and claimed you as a dependent, what was
your family’s adjusted gross income? (1040 line 7 or 1040EZ line 4) $_______________________
40. What was their taxable income? (IRS Form 1040 line 10 or IRS Form 1040EZ line 6) $_____________
41. What is the number of claimed family household members? ___ (same as in IRS Form 1040 or 1040EZ)
42. Do you or any member of your family members receive any assistance from the following?
____TANF (AFDC)
____Food Stamps
____Veterans Benefits
____Social Security Income
____Medicaid
____Unemployment Compensation
____Other, explain_____________________________________________________________
IV. Household Information
43. Did you reside with your parent(s)/guardian during the last year? ____Yes ____No
44. Where will you live while attending TAMIU? ____Home ____ Dorms ____Apartment
45. Are you considered a caretaker (responsible for taking care of other people): ___Yes ___No
a. If yes, who are you responsible for taking care of?
___Elderly person(s) ___Younger siblings ___Other____________________
b. Are you a Parent: ___Yes ___No If yes, number of children: ___ Ages of children: _________
46. What is the highest level of education completed by your parent/guardian(s)?
Mother/guardian highest education level:
___High School or below ___2-year college ___4 year college ___Other, explain_________________
Father/guardian highest education level:
___High School or below ___2-year college ___4 year college ___Other, explain_________________
47. Do you have a documented disability? ____Yes ____No
48. If yes, are you registered for services with TAMIU’s Disability Service Office? ____Yes ____No
Please note: If you are not registered with TAMIU’s Disability Service Office, you may be required to submit
written documentation by a qualified professional, physician, or state agency to verify your eligibility status.
V. Needs Assessment
49. Check all of the services that you would like to receive:
Academic Advising
Degree Counseling
FAFSA Filing Assistance
Financial Aid Counseling
Leadership Opportunities
Cultural Enrichment
Opportunities
Tutoring Assistance
Priority Registration
Selecting a Major
Career Counseling
Personal Counseling
Supplemental Financial Help
Caretaking Resources
Finding Employment
Other:_________________
TRiO SSS PY5 v3.1 04/24 4
50. Which of the following workshops would be of most interest to you?
Time Management
Self-Confidence
Note-Taking Skills
Health Issues
Coping skills
Study Habits
Stress Management
Disability Issues
Computer Technology
Microsoft Word
51. Which of the following areas would you like or do you need assistance with in order to facilitate your
academic goals?
Low Grades
Family Medical Problems
Separation/Divorce
Problems at Home
Social Integration
Lack of Transportation
Alcohol/Drug Problems
Shyness
Losing Focus
Other:
VI. Questions
52. What kind of academic challenges or obstacles do you think might interfere with or prevent you from
doing well in your classes?
53. What kind of personal challenges or obstacles might interfere with attending your university classes and/or
doing your homework and studying?
54. Briefly describe what your career goals are. What do you plan to do with your degree after you
graduate?
55. What exp
eriences at TAMIU will you find challenging? Which experiences do you anticipate are going to be
easy for you at TAMIU?
TRiO SSS PY5 v3.1 04/24 5
IV. Questionnaires
Instructi
ons: The following are two types of questionnaires that are part of the application. Please make sure that
you read the questions carefully and answer accordingly. We would like you to answer both questionnaires as
accurately and completely as possible.
GOALS & TIME MANAGEMENT QUESTIONNAIRE
Please circle the answer that best describes you.
5
Always
4
Frequently
3
Sometimes
2
Infrequently
1
Never
I make a list of the things that I have to do each day
5
4
3
2
1
I make a schedule of the activities that I have to do on work
days
5
4
3
2
1
I plan the day before I start it
5
4
3
2
1
I write a set of goals for myself for each day
5
4
3
2
1
I have a clear idea of what I want to accomplish during the next
week
5
4
3
2
1
I spend time each day planning
5
4
3
2
1
I set and follow on priorities
5
4
3
2
1
I continue unbeneficial routines or activities
5
4
3
2
1
I believe that there is room for improvement in the way I
manage my time
5
4
3
2
1
I find myself doing things which interfere with my college work
simply because I hate to say “No” to people
5
4
3
2
1
I feel I am in charge of my own time, to a large extent
5
4
3
2
1
On an average class day I spend more time with personal
grooming than doing college work
5
4
3
2
1
I make constructive use of time
5
4
3
2
1
The night before a major assignment is due, I am still working
on it
5
4
3
2
1
I have set goals for the entire semester
5
4
3
2
1
I keep my desk clear of everything other than what I am
currently working on
5
4
3
2
1
When I have several things to do, I think it is best to do a little
bit of work on each one
5
4
3
2
1
I review my class notes, even when a test is not imminent
5
4
3
2
1
I like to read class text material ahead of the lecture
5
4
3
2
1
TRiO SSS PY5 v3.1 04/24 6
THE SELF-REPORT HABIT INDEX
For each statement, please select the appropriate answer for you.
My study behavior is something… Agree Disagree
I do frequently
Agree Disagree
I do automatically
Agree Disagree
I do without having to consciously remember
Agree Disagree
That makes me feel weird if I do not do it
Agree Disagree
I do without thinking
Agree Disagree
That would require effort not to do it
Agree Disagree
That belongs to my (daily, weekly, monthly) routine
Agree Disagree
I start doing before I realize I am doing it
Agree Disagree
I would find hard not to do
Agree Disagree
I have no need to think about doing
Agree Disagree
That is typically “me”
Agree Disagree
I have been doing for a long time
Agree Disagree
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Completed 28 August 2020

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